What is the diagnosis and management of Mal de Debarquement Syndrome (MDDS)?

Clarification Regarding Mal de Debarquement Syndrome (MdDS) Diagnostic Criteria

The statement about the Bárány Society requiring symptom onset within 24 hours of motion exposure is incorrect—MdDS is diagnosed when persistent motion sensations (rocking, swaying, bobbing) begin after passive motion exposure ends, not within 24 hours of motion starting.

Correct Diagnostic Criteria for MdDS

Core Diagnostic Features

MdDS is characterized by persistent sensations of motion (rocking, swaying, or bobbing) that typically arise after exposure to passive motion ceases, not during or within the first 24 hours of motion. 1

• The Bárány Society diagnostic criteria (forthcoming publication) define MdDS as persistent vertigo triggered by passive motion exposure (water, air, or land transportation), with symptoms beginning when the motion stops 1
• Symptoms must persist beyond the normal readaptation period, often lasting weeks, months, or even years 2, 3
• The condition predominantly affects middle-aged women 1, 4

Two Clinical Subtypes

• Classic MdDS: Induced by passive transport on water or in air, accounting for approximately 85% of cases 5
• Spontaneous MdDS: Occurs without identifiable motion trigger, representing approximately 15% of cases 5

Distinguishing Diagnostic Characteristics

• Symptoms temporarily improve when the patient is re-exposed to passive motion (driving a car, bicycle riding), which is pathognomonic for MdDS 3, 5
• Unlike motion sickness, symptoms begin after the motion ceases rather than during motion exposure 2
• Diagnosis requires exclusion of other vestibular and neurological disorders through clinical evaluation 2, 1

Management Algorithm

Initial Assessment and Diagnosis

• Conduct detailed clinical history focusing on temporal relationship between motion exposure and symptom onset 5
• Assess rocking frequency, body drifting patterns, and presence of nystagmus 5
• Perform static posturography for objective baseline measurements 5
• Screen for personal or family history of migraine headaches, as nearly all MdDS patients have migraine associations 4

First-Line Treatment Approach

Manage MdDS using a vestibular migraine protocol, which demonstrates 73% response rates compared to lower success with vestibular rehabilitation alone. 4

• Implement lifestyle modifications specific to migraine management 4
• Initiate pharmacotherapy with verapamil, nortriptyline, topiramate, or combination therapy 4
• This approach significantly improves symptoms and quality of life in the majority of patients 4

Specialized Vestibular Treatment

• For patients not responding to migraine management, consider specialized vestibular treatment involving head rolling while watching rotating full-field visual surrounds for 4-5 days 5
• This treatment achieves 78% initial significant improvement (>50% symptom reduction) in classic MdDS and 48% in spontaneous MdDS 5
• At 1-year follow-up, 52% of classic and 48% of spontaneous patients maintain significant improvement 5
• Complete remission occurs in 27% of classic and 19% of spontaneous cases 5

Critical Timing Considerations

Early diagnosis and treatment significantly improve outcomes, as success is inversely correlated with symptom duration and patient age. 5

• Patients with symptoms persisting beyond 6 months have historically been described as unlikely to remit with supportive care alone 4
• However, with appropriate migraine-based management, even chronic cases can improve 4
• Avoid prolonged travel by air or car immediately after treatment, as this contributes to symptomatic reversion 5

Common Pitfalls to Avoid

• Do not dismiss MdDS as simple motion sickness—the temporal pattern (symptoms after motion stops) is distinctly different 2
• Do not rely solely on vestibular rehabilitation therapy—migraine-based management shows superior outcomes 4
• Do not delay treatment—earlier intervention correlates with better long-term results 5
• Do not overlook the migraine connection—screen all patients for migraine history as this guides effective treatment 4

Prognosis and Long-Term Management

• Most untreated cases resolve spontaneously within approximately one year, though this is highly variable 3
• With appropriate treatment, significant improvement can be achieved and maintained in approximately half of patients at 1-year follow-up 5
• Monitor for associated symptoms including fatigue, cognitive slowing, and visual motion intolerance, which contribute to morbidity 1