Is gabapentin (Neurontin) effective in treating Mal de Debarquement Syndrome (MdDS)?

Gabapentin for Mal de Debarquement Syndrome

Gabapentin is not recommended for treating Mal de Debarquement Syndrome (MdDS), as there is no evidence supporting its efficacy for this condition, and benzodiazepines have demonstrated the most consistent benefit among pharmacological options.

Evidence for Gabapentin in MdDS

• No direct evidence exists supporting gabapentin's use specifically for MdDS in any published studies or guidelines 1, 2, 3, 4, 5
• Gabapentin's established efficacy is limited to other neuropathic pain conditions (diabetic neuropathy, restless legs syndrome) and does not extend to vestibular disorders like MdDS 6

Established Treatment Approaches for MdDS

First-Line Pharmacological Treatment

• Benzodiazepines are the most consistently helpful medication class for MdDS symptom reduction, though their long-term use is limited by addiction potential 4, 5
• In a retrospective study of 27 patients, benzodiazepines provided the most benefit compared to other medications, while meclizine and scopolamine were ineffective 5
• A larger survey of 287 MdDS patients confirmed that benzodiazepines/antidepressants were reported as most beneficial in reducing symptoms 2

Migraine Prophylaxis Protocol

• Treatment with vestibular migraine management protocols showed 73% response rates in a prospective study of 15 MdDS patients 1
• This approach includes lifestyle modifications plus pharmacotherapy with verapamil, nortriptyline, or topiramate (not gabapentin) 1
• The rationale is that nearly all MdDS patients had personal or family history of migraine headaches or atypical migraine symptoms 1

Vestibulo-Ocular Reflex (VOR) Readaptation

• VOR readaptation using optokinetic stimulation with head roll achieved 64.1% success rate in 131 consecutive patients, representing the most robust evidence-based treatment 3
• This non-pharmacological approach involves fixed-protocol treatments over 2-5 consecutive days with objective improvements in posturography 3
• Success rates were equivalent between motion-triggered (64.2%) and spontaneous-onset (63.3%) MdDS 3

Why Gabapentin Is Not Appropriate

• Gabapentin's mechanism targets neuropathic pain pathways through voltage-gated calcium channel binding, which does not address the vestibular maladaptation underlying MdDS 6
• Common vestibular suppressants, which would theoretically include gabapentin's sedating effects, are nearly always ineffective in MdDS 4
• The condition improves with re-exposure to motion (opposite of typical vestibular disorders), suggesting a unique pathophysiology not responsive to standard neuropathic agents 4

Recommended Treatment Algorithm

1. Initiate VOR readaptation therapy as first-line treatment given the 64% success rate and objective outcome measures 3
2. Consider benzodiazepines for short-term symptom management while pursuing definitive treatment, with careful monitoring for dependence 4, 5
3. Trial vestibular migraine prophylaxis protocol (verapamil, nortriptyline, or topiramate) in patients with migraine history or features 1
4. Avoid gabapentin and traditional vestibular suppressants (meclizine, scopolamine) as they lack evidence and are consistently reported as ineffective 2, 4, 5

Important Clinical Caveats

• MdDS predominantly affects middle-aged women (73-96% of cases) and symptoms lasting beyond 6 months were historically considered unlikely to remit, though newer treatments challenge this 1, 4, 5
• Balance rehabilitation physical therapy alone shows minimal benefit (small average improvement in 15 patients), inferior to migraine protocol management 1, 5
• Symptom duration averages 3.5 years when untreated, emphasizing the importance of evidence-based intervention rather than empiric trials of unproven medications 5