Maladaptation of Velocity Storage in Mal de Debarquement Syndrome
The most effective approach to manage Mal de Debarquement Syndrome (MdDS) is vestibulo-ocular reflex (VOR) readaptation treatment using optokinetic stimulation paired with head roll maneuvers, which provides symptom relief in approximately 64% of patients regardless of onset type. 1
Understanding the Pathophysiology
MdDS results from maladaptive changes in the velocity storage mechanism of the central vestibular system—a polysynaptic pathway that contributes to the vestibulo-ocular reflex, spatial orientation, and self-motion perception. 2 The velocity storage mechanism becomes inappropriately adapted following prolonged passive motion exposure (cruise ships, planes, cars) or can occur spontaneously, leading to constant phantom sensations of rocking, bobbing, or swaying. 3, 4
Primary Treatment: VOR Readaptation Protocol
The standardized VOR readaptation protocol should be implemented as first-line treatment for both motion-triggered and spontaneous-onset MdDS. 1
Specific Treatment Parameters:
- Optokinetic stimulation (OKS) paired with fixed head roll at 0.167 Hz 1
- Treatment schedule: Four-minute blocks administered twice in morning and twice in afternoon, over 2-5 consecutive days 1
- Success rate: 64.1% overall (64.2% for motion-triggered, 63.3% for spontaneous-onset) 1
- Mechanism: Corrects maladapted spatial orientation of velocity storage through full-field optokinetic stimulation 2, 5
Important Caveat:
Initial treatment success may be reversed by subsequent re-triggering events (return to boats, planes, or other passive motion exposures). 2 Patients should be counseled about this risk and potentially avoid triggering situations in the months following successful treatment.
Alternative Approach: Velocity Storage Attenuation
For patients who fail VOR readaptation or experience symptom recurrence, attenuation of velocity storage contribution offers a complementary strategy with more durable results. 2
Treatment Protocol:
- Progressive low-frequency earth-vertical oscillatory rotation coupled with conflicting visual stimuli 2
- Mechanism: Reduces the gain of coupling from vestibular primary afferent signals (g0 parameter) without changing the time constant 2
- Success rate: 43% achieved at least 50% symptom reduction, with majority maintaining improvement at 6-month follow-up 2
- Advantage: More lasting remedy that shows better durability compared to VOR readaptation alone 2
Pharmacological Management as Vestibular Migraine
For patients with personal or family history of migraine, management using vestibular migraine protocols provides significant benefit. 3
Medication Options:
- Verapamil, nortriptyline, topiramate, or combinations 3
- Benzodiazepines/antidepressants reported as most beneficial by patients for symptom reduction 4
- Success rate: 73% responded well to vestibular migraine protocol including lifestyle modifications and pharmacotherapy 3
Patient Selection:
This approach is particularly appropriate for the substantial subset of MdDS patients who have migraine history or atypical migraine symptoms. 3 Nearly all MdDS patients in one study had personal/family migraine history or signs of atypical migraine. 3
Virtual Reality and Telemedicine Options
Virtual reality goggles with optokinetic stimulation programs can effectively substitute for full-field laboratory equipment, enabling clinic-based or telemedicine treatment. 5
- Limited-visual-field VR goggles (e.g., Google Daydream Viewer with stripes program) provide proof of concept for clinical utility 5
- All five patients in pilot study reported immediate improvement, with only one experiencing symptom return at 2-month follow-up 5
- This approach increases treatment accessibility for patients unable to access specialized vestibular laboratories 5
Treatment Algorithm
Initial assessment: Confirm MdDS diagnosis (constant phantom motion sensations following passive motion exposure or spontaneous onset) 3, 4
First-line treatment: VOR readaptation with standardized OKS + head roll protocol over 2-5 days 1
If inadequate response or symptom recurrence: Implement velocity storage attenuation protocol with progressive oscillatory rotation 2
Concurrent consideration: If migraine history present, add vestibular migraine prophylaxis (verapamil, nortriptyline, or topiramate) 3
Adjunctive management: Benzodiazepines/antidepressants for stress reduction and symptom control 4
Critical Pitfalls to Avoid
- Do not rely solely on vestibular rehabilitation and physical therapy—these show lower improvement rates compared to VOR readaptation protocols 3
- Do not dismiss symptoms persisting beyond 6 months as untreatable—both VOR readaptation and velocity storage attenuation can provide relief even in chronic cases 2, 1
- Do not ignore migraine history—this represents a treatable component that responds to specific pharmacotherapy 3