Rocking Dizziness and non motion triggered mal de debarquement

Timothy C. Hain, MD, • Most recent save: February 16, 2023

Introduction:

Rocking dizziness or vertigo means that one has a sensation of movement such as on a boat. Practically, there may be a sensation of periodic rotation, or a sensation of sway. The rocking sensation is rarely accompanied by true vertigo (i.e. spinning). Sometimes these patients are called "rockers". Another term that can be used is "non motion triggered mal de debarquement".

Causes of rocking dizziness:

Usually rockers are "diagnosed" with one of three syndromes that are defined by symptoms alone -- vestibular migraine, mal de debarquement, and PPPD. In essence, these are all chronic "dizzy" conditions, without any findings on testing. It is often not possible to distinguish between the diagnoses, and treatment is somewhat overlapping as well.

Feature	VM (vestibular migraine)	PPPD (persistent postural perceptive dizziness)	MdDS (Mal de debarquement syndrome)
Headache	Yes	Not required, but OK	Not required, but OK.
Improve with driving	No	No	Yes
Previous vertigo	No	Yes, or other event	Not from inner ear, but may have previous motion exposure

Calculators for these three conditions are available VM calculator, PPPD calculator, MdDS calculator. Meniere's disease is not generally in the "running" for diagnosis here because most cases of Meniere's disease have hearing loss, and if there is hearing loss, Meniere's is the usual thought.

The table above gives rough guidelines that are suggested to distinguish the 3 groups -- practically though, there is a gigantic amount of overlap. A large fraction of the population has headache (for example). Patients with MdDS (mal de debarquement) often overlap with the demographics of vestibular migraine. PPPD explicitly overlaps with VM, and can be "diagnosed" in persons who have many other conditions (Staab et al, 2017). PPPD and MdDS differ in that PPPD gets worse with "active or passive motion". Still, someone who gets better when they drive (active motion), but are worse when they are a passenger (passive motion), could meet the criteria for PPPD.

Little is know about the cause of rocking sensation. In theory, it might be due to disturbance in the vertical semicircular canals of the inner ear (see figure above), due to a disturbance in the sensors for linear acceleration, the otoliths, or a disturbance in the central connections of these structures. As presently our ability to test these structures is very limited, it is difficult to be sure. In this regard, considerable recent progress have been made in assessing the otoliths (VEMP testing).

Considering these and other causes:

• Rocking is common in a variant of motion sickness called "Mal de Debarquement syndrome". These patients generally developed rocking after a long boat ride, and improve when they drive.
• Some physicians consider "rocking" vertigo to be a "psychogenic" type of dizziness. (Afzelius, Henriksson et al. 1980). To us, we think it would be more accurate to say that these physicians did not identify the cause. PPPD is a popular type of psychogenic dizziness.
• The author of this page has encountered many patients with both rocking and headaches, suggesting migraine.
• The author of this page has encountered occasional patients who developed rocking after a brain lesion. Of course, brain lesions are sources of stress, and it is possible that these people are another example of a psychogenic dizziness. To sort this out, one would need to determine whether certain types of brain lesions are associated with rocking to a greater extent than others.
• The author of this page has also encountered occasional patients with rocking accompanying a primary visual disturbance (strabismus). Here, it would seem likely that it is variant of motion sickness.
• A similar group of individuals in age and gender (females in mid-40's) to the Mal de debarquement group, but without motion exposure, are rare but definite occasional visitors to the dizzy clinic. These have been named "non-motion triggered mal de debarquement" (I guess nMDdS), but they overlap (as do MdDS patients) with the demographics of migraine.
• Some cases have been reported of persons with nMDdS, having anomalies in their cerebral venous circulation such as a too close superior petrosal sinus resulting in SCD, as well as various situations where jugular veins are compressed by enlarged digastric muscles, bony spurs such as in Eagle's syndrome, and cervical ribs. More evidence is needed. The testing for this condition requires methods of assessing venous flow (such as MRV, CT venogram). There are many congenital anomalies of cerebral veins, and this presumably makes it difficult to separate cause from association.

Rocking, like most types of dizziness, is usually worse when individuals are under stress.

Diagnosis of rocking dizziness:

Persons with rocking should be examined by a physician with expertise in inner ear disorders as well as neurological disorders.

If you are wondering if you have PPPD, we recommend taking the PPPD questionnaire to see if it is an option.

Testing that may be recommended for rockers can include:

1. ENG test and/or VHIT test. (rules out vestibular neuritis) -- VHIT is much better tolerated. Very useful !
2. Hearing test (for possible Meniere's disease, other ear damage -- very important !)
3. VEMP test ( including both SCM (neck) and ocular type (oVEMP), diagnoses SCD) -- Very useful (especially oVEMP).
4. Rotatory chair (checking for central forms of vertigo, fixation suppression/rebound is most useful)
5. Posturography (quantifies balance, somewhat sensitive to PPPD). Can show a non-sensory unsteadiness, or high values for amplitude scaling.
6. ECOG (for Meniere's disease) -- not commonly done as Meniere's disease usually doesn't present with rocking.
7. MRI scan (for central forms of vertigo such as Chiari, stroke, MS, or tumors of inner ear). Other possible procedures include MRV and CT angiography. These are generally expensive tests with low yield. Not usually neededbut it does tick off another group of disorders.
8. CT scan of the temporal bone (for SCD). Should not be done unless a VEMP test is positive.
9. Blood tests including FTA, Sed-rate, ANA, B12 (where there is a reasonable suspicion of one of these disorders). B12 is the most useful here as it becomes common in persons with advancing age. Just check in persons with appropriate history.

Note that on the above list, we don't have any specific tests for vestibular migraine, PPPD or MdDS. The purpose of doing the above is to find something other than these three.

Treatments for vestibular migraine (VM), PPPD and MdDS.

Treatment	VM	PPPD	MdDS
SNRI (venlafaxine)	Yes	Yes (also SSRI)	Yes
Benzodiazepines	No	No	To prevent recurrence
Physical therapy and/or visual therapy	No	Yes	No
Psychotherapy (CBT)	No	Yes	No

Treatment varies somewhat by the primary diagnostic entity, but as this is often unclear, often all of the above are tried. Benzodiazepines, such as clonazepam usually are very effective for rocking in general, including MdDS, but of course are also addictive(Canceri et al, 2018). SSRIs (such as Paroxetine) or SNRI type antidepressants (such as venlafaxine) are also often worth considering, in very low doses (Liu et al, 2017). Vestibular rehabilitation therapy should also be tried, especially in PPPD. Visual rehabilitation therapy is sometimes helpful for the visual vertigo that is part o the PPPD diagnostic criteria. CBT psychotherapy is also recommended for PPPD. (Popkirov, 2018)

References:

• Afzelius, L. E., N. G. Henriksson, et al. (1980). "Vertigo and dizziness of functional origin." Laryngoscope 90(4): 649-56.
• Canceri, J. M., et al. (2018). "Examination of Current Treatments and Symptom Management Strategies Used by Patients With Mal De Debarquement Syndrome." Front Neurol 9: 943.
• Henriksson, N. G., L. E. Afzelius, et al. (1976). "Vertigo and rocking sensation. A clinical analysis." ORL J Otorhinolaryngol Relat Spec 38(4): 206-17.
• Liu, F., et al. (2017). "The Efficacy of Venlafaxine, Flunarizine, and Valproic Acid in the Prophylaxis of Vestibular Migraine." Front Neurol 8: 524.
• Popkirov, S., et al. (2018). "Persistent postural-perceptual dizziness (PPPD): a common, characteristic and treatable cause of chronic dizziness." Pract Neurol 18(1): 5-13.

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