What is the management and treatment of Mal de Debarquement (MDD)?

Management of Mal de Debarquement Syndrome (MdDS)

The most effective treatment approach for Mal de Debarquement Syndrome combines vestibular ocular reflex (VOR) readaptation therapy with pharmacological management using benzodiazepines or antidepressants, which has shown success rates of up to 64% in reducing symptoms and improving quality of life. 1

Understanding MdDS

• MdDS is a neurological disorder affecting the vestibular system, manifesting as a constant sensation of movement (rocking, bobbing, or swaying) 2
• Two main subtypes exist: Motion-Triggered (MT-MdDS) which occurs after passive motion exposure (e.g., boat or plane rides) and Spontaneous/Other onset (SO-MdDS) 2
• Predominantly affects women (approximately 80% of cases), most commonly middle-aged 3
• Symptoms persist for a month or longer, distinguishing it from temporary land-sickness 3
• Unlike other vestibular disorders, symptoms typically improve with re-exposure to motion 3

First-Line Treatment: VOR Readaptation Protocol

• VOR readaptation therapy using optokinetic stimulation (OKS) paired with head roll movements has demonstrated significant effectiveness 1
• Protocol involves:
  • OKS paired with head roll at 0.167 Hz over 2-5 consecutive days 1
  • Four-minute treatment blocks scheduled twice in morning and afternoon 1
• Success rate of 64.1% across all patients, with similar effectiveness in both MT-MdDS (64.2%) and SO-MdDS (63.3%) 1
• Early diagnosis and treatment significantly improve outcomes 4

Pharmacological Management

• Benzodiazepines have shown benefit in symptom reduction, though their use is limited by addiction potential 3
• Antidepressants (particularly SSRIs) have demonstrated effectiveness in reducing symptoms 2
• Treatment as vestibular migraine using migraine prophylaxis protocols has shown promise:
  • Verapamil, nortriptyline, or topiramate (alone or in combination) 5
  • 73% of patients responded well to this approach 5
• Common vestibular suppressants are generally ineffective for MdDS 3

Factors Affecting Treatment Success

• Duration of symptoms before treatment initiation (inverse correlation with success) 4
• Patient age (younger patients typically respond better) 4
• Prolonged travel immediately after treatment may contribute to symptomatic reversion 4
• Complete remission occurs in approximately 27% of MT-MdDS and 19% of SO-MdDS patients 4

Symptom Management Strategies

• Stress reduction techniques are particularly beneficial as stress can exacerbate symptoms 2
• Lifestyle modifications similar to those used for vestibular migraine management 5
• Physical therapy focused on vestibular rehabilitation may provide some benefit, though less effective than targeted treatments 5

Long-term Follow-up and Monitoring

• Regular assessment of symptom severity using subjective scales (e.g., visual analog scale) 1
• Objective measures like static posturography when available 4
• Monitoring for comorbid conditions, particularly migraine headaches which are more common in MdDS patients 3

Treatment Algorithm

1. Initial Assessment:

   • Confirm diagnosis through clinical history focusing on onset pattern (motion-triggered vs. spontaneous)
   • Assess symptom severity using standardized scales
   • Rule out other vestibular disorders

2. Primary Treatment:

   • Implement VOR readaptation protocol with OKS and head roll movements 1
   • Schedule 2-5 consecutive days of treatment with multiple sessions per day 1

3. Pharmacological Support:

   • For patients with partial response to VOR therapy: Add benzodiazepines or antidepressants 2, 3
   • For patients with migraine history: Consider vestibular migraine protocol (verapamil, nortriptyline, topiramate) 5

4. Follow-up Care:

   • Assess treatment response at 1-week and 1-year post-treatment 4
   • Implement stress reduction techniques and lifestyle modifications 2
   • Consider retreatment if symptoms recur after initial improvement 4

Pitfalls and Caveats

• Avoid prolonged travel immediately after successful treatment as this may trigger symptom recurrence 4
• Be aware that common vestibular suppressants are typically ineffective and may delay appropriate treatment 3
• Consider the addiction potential of benzodiazepines when using for long-term management 3
• Recognize that MdDS is often misdiagnosed due to lack of awareness among medical professionals 2
• Early intervention is critical - treatment success decreases with longer symptom duration 4