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Medical therapies for dizziness are aimed at vertigo reduction, secondary symptom management, or the root cause of the pathologic process. Acute peripheral vertigo pharmacotherapies include antihistamines, calcium channel blockers, and benzodiazepines. Prophylactic pharmacotherapies vary between causes. For Meniere disease, betahistine and diuretics remain initial first-line oral options, whereas intratympanic steroids and intratympanic gentamicin are reserved for uncontrolled symptoms. For cerebellar dizziness and oculomotor disorders, 4-aminopyridine may provide benefit. For vestibular migraine, persistent postural perceptual dizziness and mal de débarquement, treatment options overlap and include selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants and calcium channel blockers.

Įvadas. Mal de Debarquement sindromas (MdDS) yra retas otoneurologinis sutrikimas, dažniausiai pasireiškiantis vidutinio amžiaus moterims po ilgalaikio pasyvaus judesio poveikio (skrydžio lėktuvu, kruizo laivu). Sindromas pasireiškia persistuojančiu galvos svaigimu, siūbavimo pojūčiu, nestabilumu ir pusiausvyros sutrikimu. Diagnostika sudėtinga, kadangi nėra instrumentinių tyrimų, patvirtinančių šį sutrikimą, otoneurologinis ištyrimas neinformatyvus. Diagnostika remiasi anamneze, todėl MdDS retai diagnozuojamas arba nustatomas netinkamai. Autorių žiniomis, straipsnių apie šį sindromą lietuvių kalba nebuvo skelbta. Šio straipsnio tikslas – supažindinti Lietuvos gydytojus su MdDS, aprašant Lietuvoje diagnozuotus atvejus, diagnostinius kriterijus, ir apžvelgti literatūroje publikuotą informaciją. Tyrimo metodai. Aprašomi du klinikiniai atvejai, kai Mal de Debarquement sindromas buvo diagnozuotas dviem vidutinio amžiaus moterims po skrydžio lėktuvu. Abi moterys skundėsi po kelionės atsiradusiu galvos svaigimu, tačiau otoneurologinis ištyrimas galimos patologijos neparodė. Pateiktoje literatūros analizėje apžvelgtas 21 straipsnis, aprašantis MdDS. Rezultatai. Pateikti 2016 m. diagnostiniai kriterijai, padedantys diagnozuoti MdDS. Diagnostiškai reikšmingas MdDS požymis yra simptomų sumažėjimas, pacientui grįžus į pasyvaus judesio sąlygas. Dažnai sergančiuosius MdDS lydi nerimas ir depresija. Tyrimai rodo, kad efektyviam gydymui ir gyvenimo kokybei gerinti taikoma stresą mažinanti terapija, medikamentinis gydymas, kuris yra skiriamas migrenos priepuolių profilaktikai, ir gyvenimo būdo pokyčiai. Išvados. MdDS iki šiol yra retai diagnozuojamas sutrikimas daugelyje šalių. Diagnostikai svarbi klinika ir anamnezėje buvęs pasyvaus judesio poveikis. Diferencinei diagnostikai nuo kitų, panašią kliniką turinčių, ligų būtinas otoneurologinis ištyrimas.

This chapter focuses on several uncommon causes of disequilibrium in the adult. The diseases have been divided into two broad categories: those causing chronic symptoms and those causing episodic symptoms. The unusual causes of chronic disequilibrium in the adult include bilateral vestibular loss, progressive supranuclear palsy, spinocerebellar ataxias, and mal de debarquement. The unusual causes of episodic disequilibrium in the adult include psychogenic disequilibrium, vestibular paroxysmia, episodic ataxia, vestibular seizures, and cervicogenic vertigo.

Le syndrome du mal de débarquement (MdDS) est caractérisé par la persistance d'une sensation de mouvement (> 1 mois), souvent suite à un déplacement en moyen de transport. Les symptômes sont nettement diminués lors d'une nouvelle exposition à un mouvement passif. Les femmes sont plus fréquemment atteintes. Le bilan fonctionnel vestibulaire et l'imagerie cérébrale sont normaux. La fatigue chronique, les céphalées, l'hypersensibilité aux stimuli visuels sont également caractéristiques du MdDS. L'impact sur la qualité de vie est significatif. Une mauvaise adaptation du réflexe vestibulo-oculaire, un trouble de la connectivité fonctionnelle ainsi qu'un dérèglement des hormones gonadiques pourraient être à l'origine du mdDS. L'exposition à des stimulations optocinétiques et la stimulation magnétique transcrânienne ouvrent des perspectives thérapeutiques.

Most patients with the acute vestibular syndrome (AVS) have vestibular neuritis or stroke or, in the setting of trauma, a posttraumatic vestibular cause. Some medical and nonstroke causes of the AVS must also be considered. Multiple sclerosis is the most common diagnosis in this group. Other less common causes include cerebellar masses, inflammation and infection, mal de debarquement, various toxins, Wernicke disease, celiac-related dizziness, and bilateral vestibulopathy. Finally, there may be unmasking of prior posterior circulation events by various physiologic alterations such as alterations of temperature, blood pressure, electrolytes, or various medications, especially sedating agents.

The Mal de Debarquement syndrome (MdDS) generally follows sea voyages, but it can occur after turbulent flights or spontaneously. The primary features are objective or perceived continuous rocking, swaying, and/or bobbing at 0.2 Hz after sea voyages or 0.3 Hz after flights. The oscillations can continue for months or years and are immensely disturbing. Associated symptoms appear to be secondary to the incessant sensation of movement. We previously suggested that the illness can be attributed to maladaptation of the velocity storage integrator in the vestibular system, but the actual neural mechanisms driving the MdDS are unknown. Here, based on experiments in subhuman primates, we propose a series of postulates through which the MdDS is generated: (1) The MdDS is produced in the velocity storage integrator by activation of vestibular-only (VO) neurons on either side of the brainstem that are oscillating back and forth at 0.2 or 0.3 Hz. (2) The groups of VO neurons are driven by signals that originate in Purkinje cells in the cerebellar nodulus. (3) Prolonged exposure to roll, either on the sea or in the air, conditions the roll-related neurons in the nodulus. (4) The prolonged exposure causes a shift of the pitch orientation vector from its original position aligned with gravity to a position tilted in roll. (5) Successful treatment involves exposure to a full-field optokinetic stimulus rotating around the spatial vertical countering the direction of the vestibular imbalance. This is done while rolling the head at the frequency of the perceived rocking, swaying, or bobbing. We also note experiments that could be used to verify these postulates, as well as considering potential flaws in the logic. Important unanswered questions: (1) Why does the MdDS predominantly affect women? (2) What aspect of roll causes the prolongation of the tilted orientation vector, and why is it so prolonged in some individuals? (3) What produces the increase in symptoms of some patients when returning home after treatment, and how can this be avoided? We also posit that the same mechanisms underlie the less troublesome and shorter duration Mal de Debarquement.

We report the case of a 26-year-old Caucasian female with persistent sensations of forward and reverse movement with spontaneous onset. This worsened over 4 wk. The patient reported an episode of these symptoms 5 mo prior, which lasted for 3 mo before improving. Our case details the treatment of Mal de Debarquement syndrome, or Disembarkment Syndrome, in a deployed military environment. Mal de Debarquement was a term originally coined to describe the persistent sensation of rocking back and forth after disembarking a boat and returning to land. This is normal, and usually only lasts for minutes to hours. When it persists, it is called Mal de Debarquement Syndrome. The onset frequently coincides with travel and most commonly by boat, however it can also occur spontaneously as in this case. Currently, there are three different treatment options. The first involves medications that are often sedating. The second uses magnetic resonance imaging at high frequency to stimulate the areas of the brain thought to be involved. The third option is a form of physical therapy termed re-adaptation of the vestibular ocular reflex. As we were in a deployed military environment the first two options were unsafe and unavailable respectively. We employed an improvised version of re-adaptation of the vestibular ocular reflex. The patient demonstrated a 50% reduction in symptoms following 1 wk of treatment and as a result was safely able to complete her deployment.

Mal de debarquement syndrome (MdDS) is typified by a prolonged rocking sensation - for a month or longer - that begins immediately following a lengthy exposure to motion. The provoking motion is usually a sea voyage. About 80% of MdDS sufferers are women, and most of them are middle-aged. MdDS patients are troubled by more migraine headaches than controls. Unlike dizziness caused by vestibular disorders or motion sickness, the symptoms of MdDS usually improve with re-exposure to motion. The long duration of symptoms - a month or more - distinguishes MdDS from land-sickness. Treatment of MdDS with common vestibular suppressants is nearly always ineffective. Benzodiazepines can be helpful, but their usefulness is limited by the potential for addiction. Studies are ongoing regarding treatment with visual habituation and transcranial magnetic stimulation.

To present a case series of vestibular symptoms appearing after combined sailing and diving activity, and to discuss the differential diagnosis and the workup algorithm.Case series.Tertiary referral center.Three patients aged 25 to 31 years suffering from unsteadiness and movement sensations after sailing and scuba diving.Neurotologic evaluation and recompression therapy in a hyperbaric chamber.The increasing popularity of marine sports and leisure activities has resulted in the exposure of a growing number of people to unique abnormalities not encountered under terrestrial conditions. The otolaryngologist who is involved in the care of these patients is required to diagnose and treat diving-related sinus and ear injuries such as barotrauma and decompression sickness, and also to be familiar with sailing-related disorientation syndromes such as seasickness and mal de debarquement. Treatment modalities for the various abnormalities differ significantly, and early commencement of treatment is often crucial for a successful outcome.Whenever doubt exists, recompression treatment must be instituted as soon as possible because of the potential for severe sequelae if the patient is left untreated, and because the risks involved in this therapy are minimal.

Background and Purpose: Persistent mal de debarquement is an uncommon disorder occurring after a sea voyage, or a plane or train trip. Symptoms include unsteadiness, rocking sensation, visual motion intolerance, cognitive slowing, and excessive fatigue. It is thought to be a result of faulty multisensory adaptation. The purpose of this case report was to describe the use of sensory reweighting, a therapeutic approach aimed at reweighting the balance between the 3 sensory systems, to decrease symptoms and increase functional abilities of a woman with persistent mal de debarquement. Case Description: A 69-year-old woman with a 4-year history of persistent mal de debarquement after a plane trip reported a constant feeling of rocking, unsteadiness, and a loss of balance in low lighting or visually rich environments. She experienced a previous fall and had limited her social activities because of her symptoms. Interventions: Sensory reweighting therapy was administered twice a week for 10 weeks. Activities included balance training using vestibular, somatosensory, and visual challenges to vary the sensory input available. Outcomes: A 5-point increase was observed on the Berg Balance Scale, she doubled her balance time in tandem stance position, and improved from moderate to low impairment on the Dizziness Handicap Inventory. She had a significant change on the Global Rating of Change Scale. Subjectively, she felt she had improved 50% and was less disabled. Discussion: A rehabilitation approach aimed at sensory reweighting improved this patient's function and community reintegration. Her symptoms were reduced and stability and balance improved.

Mal de debarquement syndrome (MdDS) is a disorder of perceived motion most often occurring following a cruise. We report findings from a patient with MdDS who underwent a transcranial magnetic stimulation protocol to quantify cortical excitability. These data were compared to those from 40 controls. The patient with MdDS exhibited high levels of intracortical facilitation. These findings will provide insight on the pathophysiology of MdDS, and will help guide future work on this rare condition. Mal de debarquement syndrome (MdDS) occurs when habituation to passive background movement becomes resistant to readaptation to stable conditions and results in a phantom perception of self-motion. MdDS typically disappears quickly after return to stable ground; however, in rare instances the symptoms may persist for months to years (persistent MdDS). While the etiology of persistent MdDS is poorly understood, it does not appear to originate from vestibular dysfunction as vestibular tests are normal and the symptoms do not respond to vestibular therapy [2]. Rather, MdDS appears to be a disorder of neuroplasticity and sensory rearrangement [2]. To our knowledge, there have been no studies examining the neurophysiologic characteristics of the disorder. In this case study we report findings from a patient with persistent MdDS who underwent an extensive transcranial magnetic stimulation (TMS) protocol to quantify motor cortical excitability. Specifically, we quantified the duration of the corticospinal silent period using single-pulse TMS. The silent period is observed when a subject performs a slight contraction and a single TMS stimulus is applied to the motor cortex (Fig. 1a). Additionally, we quantified intracortical facilitation (ICF) and short-interval intracortical inhibition (SICI) using paired-pulse TMS. Paired-pulse TMS combines a conditioning stimulus (CP) with a test stimulus (TP) at different interstimulus intervals, and the relative change in motor evoked potential (MEP) size is expressed relative to an unconditioned test pulse. At a short interstimulus interval of 3 ms, the CP inhibits the MEP in comparison to the TP only (SICI), whereas at a longer interstimulus intervals of 15 ms it facilitates the MEP (ICF) (Fig. 1b). The patient was a 63-year-old female (160.2 cm, 77.3 kg) who complained of sensations of unsteadiness and a feeling of the floor moving under her feet after disembarking from a 7-day cruise *3.5 years ago (3/2007). She reported having to regularly reach out to steady herself against stationary objects, and that MdDS had greatly impacted her quality of life (subjective scoring of six out of ten on a visual analog scale for the impact of MdDS on her quality of life). Several other hallmark features of MdDS were present including mild cognitive slowing and transient improvement in symptoms with re-exposure to passive movement [2]. Physical examination was unremarkable. Diagnostic testing including sural sensory and peroneal motor conduction studies, needle EMG, and MRI of the brain were all normal. Additionally, the patient had unremarkable findings on Dix-Hallpike testing and the caloric reflex test. The patient did not have migraine or other primary headache as defined by the International B. C. Clark (&) Department of Biomedical Sciences, Ohio Musculoskeletal and Neurological Institute (OMNI), Ohio University, 211 Irvine Hall, Athens, OH 45701, USA e-mail: clarkb2@ohio.edu

Sea travel mandates changes in the control of the body. The process by which we adapt bodily control to life at sea is known as getting one's sea legs. We conducted the first experimental study of bodily control as maritime novices adapted to motion of a ship at sea. We evaluated postural activity (stance width, stance angle, and the kinematics of body sway) before and during a sea voyage. In addition, we evaluated the role of the visible horizon in the control of body sway. Finally, we related data on postural activity to two subjective experiences that are associated with sea travel; seasickness, and mal de debarquement. Our results revealed rapid changes in postural activity among novices at sea. Before the beginning of the voyage, the temporal dynamics of body sway differed among participants as a function of their (subsequent) severity of seasickness. Body sway measured at sea differed among participants as a function of their (subsequent) experience of mal de debarquement. We discuss implications of these results for general theories of the perception and control of bodily orientation, for the etiology of motion sickness, and for general phenomena of perceptual-motor adaptation and learning.

A survey conducted among 116 crew members of seagoing vessels confirmed that mal de debarquement (M-D) is a transient feeling of swinging, swaying, unsteadiness, and disequilibrium. None of the subjects requested medical attention, although there were isolated cases in which a strong sensation of swinging and unsteadiness caused transient postural instability and impaired the ability to drive. In most cases, the sensation of M-D appeared immediately on disembarking and generally lasted a few hours. In addition, subjects usually described bouts or attacks of M-D associated with changes in body posture, head position, or with closing of the eyes. M-D was reported by 72% of our subjects. Sixty-six percent of subjects reported a high incidence following their first voyages. A significant positive correlation was found between M-D and seasickness susceptibility. The nature of M-D may be explained within the framework of multisensorimotor adaptation and habituation to a new or abnormal motion environment. It is suggested that M-D represents a dynamic, multisensorimotor form of CNS adaptive plasticity.

This content focuses on some of the less common causes of dizziness in the adult. The diseases have been divided into the 2 broad categories of those causing chronic symptoms and those causing episodic symptoms. Presented here are the unusual causes of chronic disequilibrium in the adult, including bilateral vestibular loss, progressive supranuclear palsy, spinocerebellar ataxias, and mal de debarquement. Also discussed are the unusual causes of episodic disequilibrium in the adult, including psychogenic disequilibrium, vestibular paroxysmia, episodic ataxia, vestibular seizures, and cervicogenic vertigo.

Mal de debarquement syndrome is defined by a persistent sensation of rocking and swaying commonly felt with sea travel that is first noted on return to land. Mal de debarquement syndrome is not to be confused with seasickness, which causes nausea, vomiting, diaphoresis, and headache. Four female patients with mal de debarquement syndrome are reviewed. Mal de debarquement is normally a short-lived phenomenon. The need for extensive evaluations may be avoided by an awareness of this entity.

Mal de debarquement (MdD), the “sickness of disembarkment,” occurs when habituation to background rhythmic movement becomes resistant to readaption to stable conditions and results in a phantom perception of self motion typically described as rocking, bobbing, or swaying. Although several studies have shown that brief periods of MdD are common in healthy individuals, this otherwise natural phenomenon can become persistent in some individuals and lead to severe balance problems. Increased recognition of MdD in a persistent pathological form occurred after the publication of a case series of six patients by Brown and Baloh in 1987. Over 20 years later, although more is known about the clinical syndrome of persistent MdD, little is known about what leads to this persistence. This review addresses the clinical features of MdD, the associated symptoms in the persistent form, theories on pathogenesis, experience with treatment, and future directions for research.

To investigate the clinical features and natural history of mal de debarquement (MdD).Retrospective case review with follow-up questionnaire and telephone interviews.University Neurotology Clinic.Patients seen between 1980 and 2006 who developed a persistent sensation of rocking or swaying for at least 3 days after exposure to passive motion.Clinical features,diagnostic testing, and questionnaire responses.Of 64 patients(75% women) identified with MdD, 34 completed follow-up questionnaires and interviews in 2006. Most patients had normal neurological exams, ENGs and brain MRIs. The average age of the first MdD episode was 39+/-13 years. A total of 206 episodes were experienced by 64 patients. Of these, 104 episodes (51%) lasted1 month; 18%,1 year; 15%,2 years; 12%,4 years, and 11%,5 years. Eighteen patients (28%) subsequently developed spontaneous episodes of MdD-like symptoms after the initial MdD episode.There was a much higher rate of migraine in patients who went onto develop spontaneous episodes(73%) than in those who did not(22%). Subsequent episodes were longer than earlier ones in most patients who had multiple episodes.Re-exposure to passive motion temporarily decreased symptoms in most patients (66%).Subjective intolerance to visual motion increased (10% to 66%)but self-motion sensitivity did not(37% to 50%) with onset of MdD.The majority of MdD episodes lasting longer than 3 days resolve in less than one year but the probability of resolution declines each year. Many patients experience multiple MdD episodes. Some patients develop spontaneous episodes after the initial motion-triggered episode with migraine being a risk factor.

Mal de debarquement (MDD) is a common, benign, and self-limited syndrome suffered by many people after disembarkation from an oceangoing vessel. It is characterized by a continuing sensation of being on an unsteady pitching and rolling deck, even after a return to solid ground. Symptoms typically dissipate over several hours or days, but can linger for weeks. There is no effective treatment for MDD, no work-up is required, and patients can be reassured that the symptoms are transient. We present a case of MDD in a previously healthy 22-year-old male, and discuss the approach to MDD in the emergency department setting.

After a prolonged period of passive motion, a nonvertiginous sense of dizziness may be experienced when the subject returns to a stationary environment. Patients with this syndrome, referred to as mal de debarquement (MDD), describe a sensation of rocking, tilting, or swaying that may last from hours to years and that is generally most marked when they are stationary.1,2⇓ Possible explanations for MDD have included abnormal adaptation to motion, otolith dysfunction, migraine, or psychogenic mechanisms.1,3⇓ I describe a patient whose symptoms closely mimicked the subjective head motion dynamics associated with travel in two different cars. This case supports the contention that MDD results from an aberrant adaptive response to passive motion. A 55-year-old woman sought treatment for a 4-year history of dizziness. She described her symptoms as a sense of rocking and pitching. These symptoms invariably followed prolonged driving trips, typically occurred in episodes lasting for hours, …

Objectives To better define mal de debarquement ("sickness of disembarkment") syndrome, to understand the etiology or mechanism of this disorder, and to seek better prevention and treatment options for this disorder. Design Patient survey of clinical features. Setting Participants were recruited via advertisement in the newsletter of the Vestibular Disorders Association, Portland, Ore. Patients Twenty-seven individuals with mal de debarquement syndrome were identified. To be included in the study, patients must have experienced at least 1 month of rocking or swaying following a cruise or airplane trip of at least 4 hours in duration. Intervention A questionnaire was administered. Main Outcome Measure Clinical features of mal de debarquement syndrome. Results Nearly all respondents were middle-aged women (26 of 27; mean age, 49.3 years). The duration of symptoms ranged from 6 months to 10 years (mean, 3.5 years; SD, 2.5 years). The symptoms were constant in 23 (85%) patients. Neither meclizine hydrochloride nor transdermal scopolamine was helpful. Benzodiazepines were of the most benefit. Balance rehabilitation physical therapy was undertaken by 15 patients, who on average reported a small benefit. Conclusions More than double the number of previously reported cases of mal de debarquement syndrome were identified by this study. The syndrome usually occurs in middle-aged women following an ocean cruise. Symptoms are often refractory to vestibular suppressants as well as physical therapy.

Background Mal de debarquement (MdD) literally means "sickness of disembarkation", and refers to the illusion of movement perceived as an after-effect of traveling on a boat, train, or airplane. The pathophysiology of MdD is currently unknown. Case Report A 20-year-old man presented with dizziness and swaying sensation for 3 days after a boat trip. Compared with the follow-up EEG without symptoms, the EEG recorded while having MdD symptoms disclosed a significantly decreased alpha-band current source density at the precentral gyrus of the left frontal lobe and increased beta-2 activity at the parahippocampal gyrus of right mesial temporal region. Conclusions Our results provide evidence of deranged cortical activity in MdD. To the best of our knowledge this is the first study to document cortical correlates of MdD using an EEG source-localization method.

Mal de d?barquement, or "land sickness," is a transient sensation of tumbling, swinging, unsteadiness, and disequilibrium reported by passengers and crew after returning to land from long sea voyages. Although mal de d?barquement is mentioned in classic texts on seasickness,12 there are no specific studies concerning the nature and extent of this phenomenon. A computer search of the literature yielded only one publication dealing with persistent (not transient) mal de d?? barquement.3 We report a survey of the incidence of mal de d?barquement and its relation to experience at sea and susceptibility to seasickness.

Six patients with a distinct syndrome of persistent sensations of imbalance are presented. Common features included onset following a period of motion exposure, symptoms lasting months to years, mild unsteadiness and anxiety, minimal relief from antivertiginous medication, and normal neurologic and quantitative vestibulo-ocular examinations. One patient experienced recurrent episodes. Mal de debarquement refers to sensations of motion experienced on return to stable land after adaptation to motion lasting from hours to days in normal individuals. The presented patients exemplify a syndrome of persistent mal de debarquement. The entity is found in a relatively small number of dizzy patients. Persistent mal de debarquement is discussed in the context of what is known about long-term vestibulo-ocular adaptation to alterations of visual or vestibular environments.