The National Multiple Sclerosis Society describe multiple sclerosis (MS) as "an unpredictable, often disabling disease of the central nervous system that disrupts the flow of information within the brain, and between the brain and body."
There is an abnormal immune response experienced in those with MS. The body attacks the protective covering around the nerve fibers, disrupting communication between the brain and body. This can potentially cause permanent nerve damage and disability.
What are MS exacerbations?
An exacerbation or relapse is when a person with MS experiences a worsening of old symptoms or an onset of new symptoms. Exacerbations can range in severity from mild to severe.
A multiple sclerosis exacerbation is when MS symptoms suddenly get worse or new symptoms appear.
For it to be classed as an exacerbation, the symptoms must last for at least 24 hours. The change in symptoms must also occur at least 30 days after the last exacerbation.
Exacerbations vary in both severity and timing. Some exacerbations cause more than one symptom. Not all people affected by MS who experience an exacerbation will have the same symptoms.
While central nervous system inflammation is the cause of an MS exacerbation, there are certain things that may trigger the condition.
Triggers of an MS exacerbation can include:
- Infection: An MS relapse may be triggered by viral, bacterial, or some fungal infections. Those with MS should pay careful attention to lowering their risk of catching an infection.
- Vaccinations: Certain vaccines may be associated with triggering an MS relapse, while others may not. Some vaccines, such as those that are live like the shingles and yellow fever vaccines, are not typically recommended for people with MS.
- Stress: The role of stress in MS relapses remains unclear, however.
- Postpartum period: The time just after childbirth may leave some women with MS vulnerable to an MS relapse. Breastfeeding may offer some protection, however.
- Fertility treatments: There may be a link between fertility treatments and MS exacerbations.
- Vitamin D deficiency: There is an increased risk of an MS exacerbation when levels of vitamin D are low. Vitamin D levels should be checked regularly and boosted 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 problems
- Slurring of speech
- Bowel and bladder problems
- Sexual problems
- Emotional disturbances such as depression and mood swings
- Changes in thinking and concentration
- Hearing loss
The four types of MS and their exacerbation triggers include:
Clinically isolated syndrome (CIS)
Common symptoms of multiple sclerosis include tiredness, headaches, and weak limbs.
CIS is the first episode of central nervous system inflammation and damage to the protective coating of nerve cells. CIS produces symptoms that last for at least 24 hours.
CIS does not meet the criteria for diagnosing MS but is characteristic of the condition. Not all cases of CIS progress to MS.
People with CIS who are at an increased risk for developing relapsing-remitting MS will also have brain lesions that are typical of those seen in patients with MS. Brain lesions are scars and can be seen on MRI scans (magnetic resonance imaging).
People without brain lesions are at a lower risk for developing MS. High-risk CIS patients who are provided with early treatment may experience a delay in developing MS.
Relapsing-remitting MS (RRMS)
People who are diagnosed with RRMS will often experience exacerbations. Periods of remission may include partial or complete recovery. Often during remission, MS will not progress. These periods of recovery can last for months to years.
Primary progressive MS (PPMS)
As described by the National Multiple Sclerosis Society, PPMS is the "worsening neurologic function (accumulation of disability) from onset of symptoms, without early relapse or remissions."
Secondary progressive MS (SPMS)
This form of MS is classified as a progressive condition. In SPMS, people with RRMS continue to experience worsening of their neurological function.
There is no single test to diagnose MS. Healthcare professionals use many different tests to rule out other causes of symptoms.
Certain criteria must be met for a diagnosis of MS. The National Multiple Sclerosis Society describe the criteria as:
- At least two separate areas of damage seen in the central nervous system
- Evidence that the above damage occurred at least one month apart
- All other causes are ruled out
Some of the tests used to examine people with suspected MS include:
- MRI scanning
- Spinal tap to obtain spinal fluid samples
- Evoked potentials - measurements of the brain's electrical activity response to nerve stimulation
- Certain blood serum tests
No cure for MS currently exists. However, there are treatments to aid relapse recovery, slow disease progression, and manage symptoms.
Treatment of MS includes the use of medications, rehabilitation, and complementary and alternative therapies.
The United States Food and Drug Administration (FDA) has approved several medications for treating the various forms of MS.
Medications for injection include:
If needed, multiple sclerosis exacerbations can be treated with several different kinds of medication.
- Interferon beta-1a (Avonex, Rebif)
- Interferon beta-1b (Betaseron, Extavia)
- Glatiramer acetate (Copaxone)
- Glatiramer acetate - generic equivalent of Copaxone 20mg dose (Glatopa)
- Peginterferon beta-1a (Plegridy)
Medications taken by mouth include:
- Teriflunomide (Aubagio)
- Fingolimod (Gilenya)
- Dimethyl fumarate (Tecfidera)
Infused medications include:
- Alemtuzumab (Lemtrada)
- Mitoxantrone (Novantrone)
- Natalizumab (Tysabri)
Various treatment options exist to treat the different symptoms associated with MS. Healthcare providers will make treatment recommendations based on the symptoms the patient is experiencing.
Rehabilitative services can be included in the care of a person with MS 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 patients may find complementary alternative therapies useful. These include the use of acupuncture, diet modification, massage, exercise, yoga, meditation, and stress management.
Additionally, to treat symptoms of MS-related pain and muscle problems, the American Academy of Neurology recommend using oral cannabis.
How are exacerbations of multiple sclerosis treated?
Exacerbations can be mild or severe and last anywhere from a few days to several months. Treatment may or may not be required, as most mild symptoms such tiredness may go away on their own.
Medications used to treat exacerbations include:
- High-dose oral prednisone (Deltasone)
- High-dose intravenous methylprednisolone (Solu-Medrol)
- ACTH (H.P. Acthar Gel)
Another option for treating MS exacerbations is plasmapheresis or a plasma exchange. During this therapy, plasma is separated from the blood cells, mixed with a water-soluble protein called albumin, and introduced back into the body.
People with MS should speak to their healthcare team to see what the best approach is to treat their MS exacerbations. Rehabilitation programs may be a beneficial option as well.