Multiple sclerosis is a condition that results in nerve damage. People with multiple sclerosis sometimes experience exacerbations where old symptoms get worse or new ones develop.
In multiple sclerosis (MS), a person experiences an abnormal immune response. The body attacks the protective covering around the nerve fibers, disrupting communications from the brain.
This can potentially cause permanent nerve damage and disability.
Estimates vary as to how many people MS affects. The National Institutes for Neurological Diseases and Stroke (NINDS) estimate that 250,000–350,000 people in the U.S. have MS, but they note that it is difficult to know the exact number. The National Multiple Sclerosis Society put the number closer to 1 million.
In this article, we look at the different types of MS exacerbations or relapses and how to recognize and manage them.
Knowing when an exacerbation or relapse is taking place is critical, as receiving treatment early on can help reduce the impact of an exacerbation on everyday living.
A new MS exacerbation would have the following criteria:
- Previous symptoms have become more severe, or new symptoms have started growing evident.
- Symptoms have persisted for longer than 24 hours. More commonly, symptoms last for weeks or even months.
- A period of 30 days must have passed since the start of the previous relapse.
- A healthcare professional has ruled out other possible causes for flare-ups, including infections, heat, and stress.
Certain flare-ups of symptoms can occur for a variety of reasons, but these typically resolve without active treatment and would not qualify as exacerbations.
- Symptoms getting worse in high or low temperatures that resolve after moderate temperature resumes.
- Daily fluctuations in symptoms that may vary without reason, or might occur due to fatigue or stress.
- A mild bout of infection that makes symptoms worse without triggering a full relapse, such as a stomach bug.
Common relapse symptoms
The most common symptoms of MS that occur during a relapse include:
- balance, coordination, and dizziness issues
- vision problems
- bladder weakness
- leg or arm weakness
- numb sensations
- pins and needles
- reduction in mobility
- memory and concentration issues
Some relapses are mild and do not severely impede on daily functioning. Others will require hospitalization.
Possible triggers of an MS exacerbation can include:
- Infection: Viral, bacterial, and fungal infections may trigger an MS exacerbation. People with MS may wish to take steps to reduce their risk of infection, such as avoiding people with colds.
- Vaccinations: Certain vaccines may have links to triggering an MS relapse. Doctors do not recommend some vaccines for people with MS, such as those shots that contain live pathogens, including the vaccines for shingles and yellow fever.
- Childbirth: Exacerbations might occur during the time just after childbirth in some women who have MS. Breastfeeding may offer some protection, however.
- Vitamin D deficiency: Low levels of vitamin D can contribute to the risk of MS exacerbations. People with MS should regularly monitor vitamin D levels and boost them when appropriate.
Common symptoms of MS can include:
- limb numbness or weakness
- tingling or itching
- tremors, unsteadiness, or coordination problems
- partial or complete loss of vision
- double vision
- breathing or swallowing difficulties
- slurring of speech
- bowel and bladder problems
- sexual problems
- emotional disturbances, such as depression and mood swings
- changes in thinking and concentration
- hearing loss
During exacerbations, these will start to flare or get worse. Depending on the type of MS, these will either recover during a remission period or become permanent.
Exacerbations work differently in each type of MS.
Clinically isolated syndrome
Clinically isolated syndrome (CIS) is the first episode of central nervous system inflammation and damage to the protective coating of nerve cells. It produces symptoms that last for at least 24 hours.
People with CIS sometimes develop brain lesions typical of people with MS. These lesions usually suggest a higher risk of developing relapsing-remitting MS (RRMS). Brain lesions are scars, and they usually show up on MRI scans.
Not all people with CIS develop MS. However, since 2017, diagnostic criteria have indicated specific findings on an MRI that suggest earlier damage in a different location in the brain, as well as active inflammation in a region that is not causing the episode of symptoms.
People who have CIS without these brain lesions have a lower risk of developing MS. High-risk CIS patients who receive early treatment may experience a delay in developing MS.
Relapsing-remitting multiple sclerosis
People who have a diagnosis of RRMS will often experience exacerbations. These have a clear start and end point. Symptoms will recover either partially or fully outside of these attacks.
Sometimes all symptoms improve, but specific symptoms may persist and become permanent during other times.
During remission, MS will not often progress. These periods of recovery might last for months or years. Relapses will often lead to changes in MRI results as new brain lesions occur.
RRMS is the most common type of MS, making up 85 percent of initial diagnoses for MS.
Primary progressive MS
Primary progressive MS, or PPMS, is an escalating type of MS that gets worse from the start of any symptoms without any early remissions or relapse. Symptoms may go through periods of not being active or not progressing, but they do not get better.
Exacerbations do not often occur in PPMS, as the symptoms get worse without remission.
Around 15 percent of people with MS have the PPMS form of the condition.
Secondary progressive MS
This form of MS, which specialists abbreviate to SPMS, is a progressive condition.
It usually starts with a period of RRMS that later develops into a type in which brain and nerve function become gradually worse without periods of remission. People are more likely to experience exacerbation during this initial episode of RRMS.
Every person’s experience with RRMS, PPMS, and SPMS will be different, with varying symptoms escalating at different rates.
No single test can diagnose MS. Doctors use many different tests to rule out other causes of a person’s symptoms.
Symptoms must meet specific criteria for a doctor to make a diagnosis of MS. The National Multiple Sclerosis Society define the criteria as:
- at least two separate areas of damage in the central nervous system
- evidence that the above damage occurred at least one month apart
- the ruling out of all other possible causes
Some of the tests that doctors may use to help identify MS include:
- MRI scanning
- spinal tap to obtain spinal fluid samples
- evoked potentials, or measurements of the brain’s electrical activity response to nerve stimulation
- certain blood serum tests
People experiencing an exacerbation might find that they need to make adjustments in their personal lives to allow for a relapse to pass as comfortably as possible.
Home life and chores: Less mobility and fatigue can reduce a person’s ability to complete all their usual tasks around the home. Ask friends or family for help with daily chores and tasks. Alternatively, short-term home care can provide support.
Emotional impact: An MS relapse can take a toll on emotional well-being. Exacerbations might occur without warning, causing frustration, anger, and anxiety about the future and leading to similar feelings in the people around the individual with MS.
Relapses can lead to concerns about work and relationships, as well as sleep issues due to medications and physical pain.
Know that the feelings during an exacerbation are not forever and will become easier once symptoms pass or improve.
Work: When possible and necessary, during a relapse, take time off work. If this is not possible, then an individual can talk to their manager about working fewer hours or having a more flexible arrangement.
Cognitive difficulties: During an exacerbation, thoughts might be slower and concentration difficult.
These effects might be due to the stress of a relapse being overwhelming but can also be a direct effect of the exacerbation. Doctors refer to this as a cognitive relapse.
While these symptoms will often pass, people may wish to seek support from an occupational therapist or neuropsychologist. They will be able to help the individual manage the cognitive effects of an MS exacerbation.
The following actions might also help a person prepare for the effects of an exacerbation:
- Keeping track of daily MS symptoms plus physical or cognitive changes in a symptom log.
- Having a dedicated emergency contact to call if a relapse occurs, and a contingency plan in case they do not respond.
- Developing a support network, having a list of people who can assist with more difficult tasks, and opening a dialogue about needing help at times.
- Knowing the sick leave and return-to-work policy for your employer, or the benefits to which self-employed people are entitled if they cannot work for health reasons.
- Having a supply of everyday essentials, including milk and food with long expiry dates, toiletries, and easy meals.
People may or may not need treatment for exacerbations, as most mild symptoms, such as fatigue, may resolve without intervention.
In more severe cases, medications that doctors use to treat exacerbations include high-dose oral and intravenous (IV) methylprednisolone. Methylprednisolone is a steroid that can help reduce inflammation.
Another option for treating MS exacerbations is plasmapheresis, or a plasma exchange. During this therapy, the medical team separates plasma from the blood cells, mixes it with a water-soluble protein called albumin, and introduces it back into the body.
People with MS should speak to their healthcare team, and gauge the best treatment approach for their MS exacerbations. Physical rehabilitation programs may also provide benefit.
Treatment for MS
No full cure for MS currently exists. However, a range of treatments can help recovery during relapses, slow the progression of the disease, and help manage symptoms.
Treatment of MS includes the use of medications, rehabilitation, and complementary and alternative therapies.
The United States Food and Drug Administration (FDA) have approved several medications for treating the various forms of MS.
Medications for injection include:
- interferon beta-1a (Avonex, Rebif)
- interferon beta-1b (Betaseron, Extavia)
- glatiramer acetate (Copaxone)
- glatiramer acetate, a generic equivalent of Copaxone 20 milligram dose (Glatopa)
- peginterferon beta-1a (Plegridy)
Oral medications include:
- teriflunomide (Aubagio)
- fingolimod (Gilenya)
- dimethyl fumarate (Tecfidera)
- siponimod (Mayzent)
- cladribine (Mavenclad)
Infused medications include:
- alemtuzumab (Lemtrada)
- mitoxantrone (Novantrone)
- natalizumab (Tysabri)
Various treatment options are available for the different symptoms of MS. Doctors will customize treatment, depending on the specific symptoms that the individual with MS is experiencing.
A person with MS can include rehabilitative interventions in their treatment plan to help with everyday tasks. These services typically include physical, occupational, vocational, and cognitive therapies, as well as speech-language pathology services.
In addition to mainstream MS treatment, some people may find complementary alternative therapies useful. These include the use of acupuncture, diet modification, massage, exercise, yoga, meditation, and stress management.
The American Academy of Neurology advise that medical marijuana might also help treat some symptoms of MS-related pain and muscle problems.