Timothy C. Hain, MD • Page last modified: December 16, 2022
MdDS main page is here •MdDS calculator •Bertec-Gyrostim •PT •TMS •OKN. •references.
A review article about MdDS treatment can be found in Frontiers online (Canceri et al, 2018), and this might be a good place to start.
MdDS often ends by itself, typically within 4 months (median duration according to Cha et al, 2008). There are also some medications to suppress rocking or, in theory, to speed up resolution of the symptoms. Medication is reportedly the most effective(Cancieri et al, 2018), but there can be some "mild mood altering" side effects with the tranquilizer or antidepressants generally used.
If "waiting it out" doesn't work, and medication fails or is just not chosen, then some patients go for roll-adaptation/habituation -- the logistics are difficult however (see below).
This page mainly discusses medication treatments for MdDS (mal de debarquement syndrome). There are several other pages linked to above involving sometimes expensive devices with especial attention to the amount of evidence available to support their use. Of course, "lack of proof" is logically not at all the same as "proof of lack". So perhaps some of these treatments will eventually be shown to be effective for MdDS.
Medications appeared to be the most effective treatments for MdDS in the Cancieri et al study (2018).
While the observation has been made that patients with MdDS generally feel better, and have less rocking on a variety of medications, to our knowledge, there have been no placebo controlled blinded studies of any medication in MdDS. In the author's first paper on MdDS (Hain et al, 1999), which was a survey study, it was observed that many medications were tried, but only a few were reported as useful (Klonopin and Amitriptyline). Subsequent literature remains at the anecdotal level.
Medications that may be recommended for MdDS (but have no formal evidence that they work) include:
- Gaba agonists -- mainly the benzodiazepines
- Klonopin (generally the most used)
- Diazepam (valium)
- Migraine prevention medications (see Ghavami et al, 2016).
- Nortriptyline or amitriptyline (very reasonable)
- Gabapentin (little used)
- There are many others
A survey, carried out by Cancieri et al (2018), obtained responses to Survey monkey and Qualtrics questionnaires from 370 subjects, located throughout the world. They reported (from their online respondants of course), that "Benzodiazepine/Antidepressant use was the most commonly trialled treatment in both MT and SO groups, 64.7 and 67.3%, respectively, (Figure 1A, Table 2), followed by vitamin/mineral supplementation (47.9% and 51.0%). " They use MT to indicate motion triggered, and SO to indicate spontaneous onset. These subjects were not examined in person, and thus it might be difficult to exclude disorders such as BPPV, bilateral loss, or vestibular neuritis, that are identified with physical examination or tests.
The Bottom Line regarding medications for MdDS:
Our "executive summary" of the following long discussion -- there are just two medications seriously worth considering -- clonazepam, and venlafaxine
Clonazepam is a "suppressive" medication -- i.e. a "band aid", and probably doesn't speed up resolution. It is addictive - -a big problem. Venlafaxine is not a "suppressive" type drug, but it is a little psychoactive and may reduce anxiety. Our guess is that it does speed up resolution (but this is just a guess).
We think the best protocol is to use venlafaxine to attempt to speed up recovery, and use clonazepam or a similar drug when anticipating a relapse (such as taking a long trip). The reasoning for both is that one needs both a daily "prevention" type medication, and also it is probably important to avoid relapses, as with each relapse, there is a tendency for the duration of the symptoms to last longer (Cha, 2008). These ideas are just our opinion -- so far, studies are lacking.
With respect to all of the other medications discussed below, well it is good to keep an open mind, but we don't think one needs to try them all.
Details about medications in MdDS:
More detailed comments follow: The majority of the information here is either from mentions of a response in published papers, or the author's experience (more than 250 MdDS patients).
- Low doses of clonazepam, a benzodiazepine medication related to Valium (diazepam), are helpful in most persons with MdDS. There is some worry that these medications may prolong the duration of symptoms (although this worry has not yet been tested by a research study). These medications increase GABA. These benzodiazepine medications are also addictive, which is worrisome. We presently do not favor constant use of clonazepam for MdDS. Rather, we usually suggest occasional "emergency" use. Still, if this medication allows an individual to remain functional, exceptions are sometimes reasonable.
- We have also had some success with treatment of MdDS with venlafaxine - -this is an antidepressant that is very useful in migraine. We use the same protocol as for treatment of migraine (top dose typically only 37.5 XL). Others have reported (in 2016 at COSM meeting) that treatment with migraine medications (e.g. nortriptyline, verapamil) is successful in about 60% of the time. Ghavami et al (2016) reported improvement in 15 patients with MdDS administered a mixture of lifestyle changes, as well as verapamil, or topiramate, or nortriptyline, or a combination.. While encouraging, this needs more investigation and it is not really borne out by other studies. With venlafaxine in particular, the obvious question is how much of the effect is from the effect on mood and how much is from the effect on whatever the core driver is for MdDS. Other medications (such as topiramate or verapamil) have little effect on mood, but they have their own issues (e.g. word finding problems with topiramate, low blood pressure/constipation with verapamil).
- Occasional patients have reported improvement from treatment with Neurontin (gabapentin). This is generally in very large doses (e.g. 2400 mg, although one would think that 900 would be plenty). We think the side effects exceed the benefits.
- We have been told by two people that testosterone (for another purpose) was associated with remission of MdDS. One of the stories is below in the anechdote section. Another told us that testosterone made them worse. While MdDS is associated with estrogen (as it mainly occurs in women), it would also follow that as it is occurs mainly in women, this also means mainly in individuals with relatively little testosterone. Right now, this is not something that is being actively investigated, but we would be interested in more stories (if they exist) about what has happened in situations where testosterone is administered for another purpose, in an individual with MdDS. So far, this is just on an anecdotal level.
- We have also had occasional patients respond to tiagabine (Gabatril) (another gaba medication similar to clonazepam- there is a theme here !)
- Occasionally persons with rocking due to other causes respond to one of the SSRI type antidepressants, and this may also be worth considering. Paroxetine is the most common SSRI used in persons with dizziness.
- There are a few reports of a good response to Sinemet, which the brand name of a medication (carbidopa-levodopa) that increases dopamine. As dopamine is a precursor to many neurotransmitters, including norepinephrine, increased dopamine may be working downstream to increase the levels of these neurotransmitters. It seems unlikely to us that dopamine deficiency is the cause of MdDS, as there is an immense population of people with dopamine deficiency (i.e. Parkinson's patients), that hugely exceeds the number of people with MdDS or rocking.
- "One-off" treatments -- we are not sure, would be interested if others have had a good or bad effect.
- We have been told that non-steroidal anti-inflammatory medications have helped MdDS, but this does not seem to be a general pattern. Perhaps the mechanism here is quieting down migraine.
- phenytoin and carbamazepine (or oxcarbazepine) may be useful in reducing symptoms. Phenytoin has been reported useful in motion-sickness. A controlled trial of these medications may be in order if more evidence accumulates.
- We have been told that the "non-THC" form of medical marijuana, a CBD product, was helpful in several cases. Again, more evidence is needed.
Medications that don't work for MdDS (athough no formal studies):
After MdDS has started, most medications that work for other forms of dizziness or motion sickness are ineffective. Conventional vestibular suppressants that affect anticholinergic pathways such as meclizine and transdermal scopolamine are not helpful in MdDS. (Hain, Hanna et al. 1999) Antivert (bonine, meclizine), dramamine, and scopolamine seem to be of little use. The author has tried out many other medications, and has also not found response to more unusual agents for dizziness such as betahistine, baclofen, or verapamil.
Medications to stop and procedures to consider stopping (no studies here either).
- Female hormones
- estrogen or progesterone might be problematic because nearly all MdDS patients are women, and most are of child-bearing age-- it might be worth a trial of stopping them if this is practical. See Mucci et al (2018) for more about estrogen. It may be that hormonal fluctuations are the cause, not estrogen itself. If so, constant estrogen (such as in HRT), might even be helpful.
- There have been some reports that testosterone is helpful (see above).
- In our opinion, none of the following has any reasonable role in treating MdDS, although we would definately listen to anyone who had success. There is more discussion about some of these medications on our placebo page. MdDS is reminiscent of Meniere's disease in regards to the inventivness of treatment protocols.
- Chiropractic -- hard to see how the spine has anything to do with MdDS.
- Cranio-sacral therapy (feels nice though)
- Dangerous medications of any type seem unwise to us.
- Herbal medications in general
- Vitamins (such as lipoflavenoids) -- see placebo page
- Ear drops, magnets, sea-bands, -- see placebo page
- Vision therapy, including rose-colored or prism glasses. There is rationale for this in visual vertigo however.
Periodically we get patients email us with positive information about unusual treatments. The author of this page does not endorse these treatments, but we welcome the input and will copy them as they come in here (unless this page gets overloaded). These emails are excerpted with the permission of the authors.
5/15/2022: Psilocybin (a hallucinogen). An individual who reported 2 bouts of MdDS wrote: "I did a macrodose of 4g over the weekend, and while it didn’t completely resolve the symptoms, it did reduce them by about 50% right away. I am planning to continue to microdose and monitor my symptoms, and if they don’t resolve in about a month, I might try another macrodose and report back. I am also a migraine sufferer, and microdosing psilocybin has also alleviated my migraines to a degree."
11/26/2022: Testosterone. A man emailed me "I have had a great deal of success from taking Androgel. I do question if it is not in some unknown way prolonging the disorder, but all the evidence I have suggests it is essential to my recovery. In short, I discovered that the primary benefit of taking testosterone was in stopping the steep drop of testosterone that occurs in the morning. I adjusted my dosage and timing to target that drop. The most severe symptoms seemed to be starting at about the same time every day. I suspected that this was the same time that my testosterone was naturally declining in its daily cycle. The severe symptoms stopped immediately after what I believe was the proper dosage and timing to achieve a plateau of my daily testosterone chart. I also believe that by simply raising overall testosterone to normal levels that there is a protective effect that will prevent re-triggering the disorder, but I can not prove that. "
There are many open questions concerning treatment of MdDS. Here are a few: