What is the best management approach for Mal de debarquement syndrome?

Management of Mal de Debarquement Syndrome

The most effective treatment for Mal de Debarquement Syndrome is vestibulo-ocular reflex (VOR) readaptation therapy using optokinetic stimulation paired with head roll movements, which achieves significant improvement in approximately 64% of patients regardless of whether the onset was motion-triggered or spontaneous. 1

First-Line Treatment: VOR Readaptation Protocol

The standardized VOR readaptation protocol should be implemented as the primary treatment approach for MdDS:

• Treatment consists of optokinetic stimulation (OKS) paired with fixed head roll at 0.167 Hz delivered over 2-5 consecutive days. 1
• Each treatment day includes four 4-minute treatment blocks: two in the morning and two in the afternoon. 1
• This protocol achieves a 64.1% overall success rate, with no significant difference between motion-triggered (64.2%) and spontaneous onset (63.3%) subtypes. 1

Critical Timing Considerations

Early diagnosis and treatment significantly improve outcomes, as treatment success is inversely correlated with both symptom duration and patient age. 2

• Initial treatment achieves 78% significant improvement in classic (motion-triggered) MdDS and 48% in spontaneous MdDS. 2
• At 1-year follow-up, 52% of classic and 48% of spontaneous patients maintain significant improvement (>50% symptom reduction). 2
• Complete remission occurs in 27% of classic and 19% of spontaneous MdDS patients. 2

Important Caveat About Post-Treatment Travel

Prolonged travel by air or car immediately after successful treatment contributes to symptomatic reversion. 2 Patients should be counseled to minimize passive motion exposure in the weeks following VOR readaptation therapy to maintain treatment gains.

Second-Line Pharmacological Management

If VOR readaptation is unavailable or provides insufficient relief, pharmacological management using a vestibular migraine protocol should be implemented:

Rationale for Migraine-Based Treatment

Nearly all MdDS patients have either a personal or family history of migraine headaches or demonstrate signs/symptoms of atypical migraine. 3 This observation supports treating MdDS as a vestibular migraine variant.

Specific Pharmacological Agents

The vestibular migraine protocol includes lifestyle modifications combined with pharmacotherapy using verapamil, nortriptyline, topiramate, or combinations thereof. 3

• This approach achieves symptom improvement in 73% of MdDS patients (11 of 15 treated). 3
• Benzodiazepines and antidepressants are reported as most beneficial in reducing symptoms across both motion-triggered and spontaneous onset subtypes. 4

The proposed mechanism is that these medications reduce stress and modulate central vestibular processing, which appears central to MdDS pathophysiology. 4

Adjunctive Therapies Under Investigation

Intermittent theta burst stimulation (iTBS) over the dorsolateral prefrontal cortex combined with VOR rehabilitation shows promise but currently lacks evidence of superiority over VOR rehabilitation alone. 5

• Both active iTBS and sham iTBS groups showed significant improvements in subjective and objective outcomes when combined with VOR rehabilitation. 5
• No between-group differences were observed, suggesting VOR rehabilitation itself drives the therapeutic benefit. 5

Treatment Algorithm

1. Implement VOR readaptation protocol as first-line therapy (2-5 consecutive days of OKS with head roll). 1
2. If VOR readaptation is unavailable or contraindicated, initiate vestibular migraine protocol with lifestyle modifications plus verapamil, nortriptyline, or topiramate. 3
3. For refractory symptoms, consider benzodiazepines or antidepressants for their stress-reducing and symptom-modulating effects. 4
4. Counsel patients to avoid prolonged passive motion (air/car travel) for several weeks post-treatment to prevent symptomatic reversion. 2

Common Pitfalls to Avoid

Do not delay treatment while pursuing extensive diagnostic workup—early intervention correlates with better outcomes. 2 The diagnosis is primarily clinical, based on the characteristic constant sensation of rocking, swaying, or bobbing that typically follows passive motion exposure.

Do not rely solely on vestibular rehabilitation or physical therapy as monotherapy—these approaches show lower improvement rates compared to VOR readaptation or migraine-based protocols. 3 Standard vestibular rehabilitation demonstrated only 33% improvement versus 93% with VOR readaptation in comparative analyses. 3