Managing multiple sclerosis exacerbations

Multiple sclerosis (MS) exacerbations involve a worsening of existing symptoms or the appearance of new ones. Medical treatment, counseling, stress management and dietary and lifestyle choices may help prevent or manage an exacerbation.
In MS, the body attacks the myelin sheath, which is the protective covering around the nerve fibers, disrupting communications from the brain. This can lead to various symptoms, ranging from muscle weakness to changes in thinking and memory.
MS
muscle weakness
An exacerbation — also known as a relapse, a flare-up, or an attack — is a period when disease activity increases. Exacerbations can last from several days to several months, although the latter is rare.
known as
several days
Experts do not know precisely what causes exacerbations. However, there may be a link between high levels of inflammation and structural changes in the brain. Some triggers, such as an infection, may increase the risk.
there may be
inflammation
infection
In this article, we look at what triggers MS exacerbations, how they affect people with different types of MS, and how to recognize and manage them.
Triggers
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Possible triggers of an MS exacerbation include:
infections
vaccinations
childbirth
stress
stress
low levels of vitamin D
vitamin D
sleep disturbances
sleep
Below, we discuss each of these potential triggers in detail.
Viral, bacterial, and fungal infections may trigger an MS exacerbation.
may trigger
People with MS may wish to take steps to reduce their risk of infection, such as washing their hands frequently and speaking with a doctor about appropriate vaccinations.
It is unclear whether vaccinations worsen the symptoms of MS or not. There are concerns that some live vaccines, such as the shingles or yellow fever vaccines, may have this effect.
unclear
However, an infection may be more likely than a vaccine to trigger an exacerbation. Anyone with concerns should discuss vaccination with a healthcare professional.
Can I have a COVID-19 vaccination with MS?
Can I have a COVID-19 vaccination with MS?
People with MS usually find that disease activity decreases during pregnancy.
However, up to 30% of people may experience exacerbations in the first 3 months after delivery. This is more likely if a relapse occurred during pregnancy or just before or around the time of conception.
30%
Here, learn more about how MS affects pregnancy.
Here, learn more about how MS affects pregnancy.
Stress may trigger MS exacerbations, although research has not yet confirmed this.
research
Low levels of vitamin D can contribute to the risk of MS exacerbations. A person with MS should regularly monitor their vitamin D levels and boost them when appropriate.
vitamin
can contribute
A small 2017 study suggests that sleep disturbances or lack of sleep may trigger a relapse in people with MS.
2017 study
Recognizing an exacerbation
It is important to recognize when a relapse occurs, as prompt treatment can help reduce the impact of an exacerbation on a person’s ability to function in daily life.
A new MS exacerbation would have the following criteria:
following criteria
Previous symptoms have reappeared or worsened, or new symptoms have emerged.
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 of symptoms, such as heat or an underlying infection.
A person may also experience temporary flare-ups of symptoms that typically resolve without active treatment and do not involve additional damage to the myelin sheath. These do not qualify as exacerbations. Health experts call them pseudoexacerbations.
may also experience
do not qualify
Examples include:
symptoms getting worse in high or low temperatures that resolve after moderate temperature resumes
daily fluctuations, for example, due to fatigue or a peak in stress or activity levels
fatigue
a mild infection that makes symptoms worse without triggering a full relapse, such as a stomach bug
The most common symptoms of MS that occur during a relapse include:
balance and coordination issues
balance
dizziness
dizziness
fatigue
vision problems
vision problems
bladder weakness
bladder weakness
leg or arm weakness
numbness
tingling
reduction in mobility
issues with memory and concentration
Some relapses are mild and do not have a severe impact on daily functioning. Others will require hospitalization.
General symptoms of MS
Common symptoms of MS can include:
can include
numbness or weakness
muscle spasms and stiffness
muscle spasms
stiffness
pain
pain
tingling or itching
tremors, unsteadiness, or coordination issues
vision changes
vision changes
breathing or swallowing difficulties
breathing
swallowing difficulties
slurred speech
tiredness
bowel and bladder problems
sexual difficulties
depression
depression
changes in thinking and concentration
mobility issues
During exacerbations, one or more of these may appear or worsen. They may then improve or disappear during a remission, or they can become permanent.
How exacerbations occur with different types of MS
Exacerbations work differently in each type of MS.
Clinically isolated syndrome (CIS) is the first episode of CNS inflammation and damage to the protective coating of nerve cells. It produces symptoms that last for at least 24 hours.
Clinically isolated syndrome (CIS)
CNS
24 hours
CIS usually develops in young adults and affects the spinal cord, brain stem, or optic nerve.
usually
spinal cord
Not everyone who experiences CIS will develop MS. Some people have no further symptoms.
However, some individuals who experience CIS go on to receive a diagnosis of MS. Those people usually have specific brain lesions that show up in imaging tests.
brain lesions
If tests show that a person with CIS has those brain lesions, there is a 60–80% likelihood of developing MS within a few years. For this reason, a doctor may recommend treatment to help prevent further symptoms from occurring.
60–80%
People with a diagnosis of relapsing-remitting MS (RRMS) will often experience exacerbations in the form of a relapse that has a clear start and endpoint.
relapsing-remitting MS (RRMS)
Sometimes, all symptoms improve, but specific symptoms may persist and become permanent.
may persist
During remission, MS will not often progress, and there will be no exacerbations. A person may have no symptoms for several months or years. When a relapse occurs, MRI results may show new brain lesions.
MRI
RRMS is the most common type of MS, and around 70–80% of people with the condition have this type as an initial diagnosis.
70–80%
Primary progressive MS (PPMS) is an escalating type of MS that worsens from the time symptoms appear. There is no early remission or relapse. Symptoms may go through periods of not being active or not progressing, but they do not get better.
Primary progressive MS (PPMS)
Individuals with PPMS may not experience exacerbations, as the symptoms get worse without remission.
may not experience
Around 15–20% of people with MS have the PPMS form of the condition.
15–20%
This form of MS, which specialists abbreviate to SPMS, is a progressive condition.
In the early stages, there are times of relapse and remission. In time, however, symptoms start to worsen without periods of remission. Exacerbation is more likely to occur in the early stages.
Every person’s experience with RRMS, PPMS, and SPMS will be different. Symptoms will vary between individuals and will progress at different rates.
will be different
Learn more about the different types of MS here.
Learn more about the different types of MS here.
Diagnosis
No single test can diagnose MS or an MS exacerbation. A person may notice if pain or other symptoms increase. They may need medical help to manage worsening symptoms.
During a relapse, an MRI scan may show signs of new brain or spinal cord lesions since the previous test.
Experts believe there may be a link between high inflammation levels and these changes.
Experts believe
Lifestyle measures to manage exacerbations
During an exacerbation, a person might find that making lifestyle changes can help improve their comfort and quality of life.
Tips include:
following a heart-healthy diet to reduce the risk of cardiovascular complications
heart-healthy diet
reduce the risk
adopting strategies to manage or reduce stress, as this may play a role in exacerbations
consulting the healthcare team about an exercise plan
exercise
considering complementary therapies, such as yoga and acupuncture
yoga
acupuncture
quitting or avoiding smoking, if applicable
smoking
getting someone to help with chores and complex administrative tasks
Some of these tips, such as avoiding smoking, may also help prevent exacerbations.
help prevent
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Treatment for exacerbations
Individuals experiencing an exacerbation should contact a doctor as soon as possible.
Not everyone needs treatment for an exacerbation. Mild symptoms, such as fatigue, often resolve without intervention. However, a doctor may recommend treatment to manage specific symptoms, such as vision changes and muscle weakness.
For more severe symptoms, they may prescribe:
may prescribe
a high dose of steroids to help reduce inflammation
steroids
plasmapheresis, or plasma exchange, which involves separating plasma from the blood cells, mixing it with a protein called albumin, and returning it to the body
plasmapheresis
physical rehabilitation and other therapies to help with everyday living
counseling for mental health support
Long-term medications for MS — known as disease-modifying therapies — can help reduce the frequency and severity of exacerbations. A doctor may recommend these drugs as soon as a person receives a diagnosis of MS.
can help reduce
Treatment will depend on the individual, the type of MS diagnosis they have, and the symptoms involved.
The American Academy of Neurology advises that medical cannabis might also help treat some symptoms of MS-related pain and muscle problems.
American Academy of Neurology
What are the treatment guidelines for MS?
What are the treatment guidelines for MS?
Summary
MS exacerbations — also known as relapses, exacerbations, or flare-ups — occur when symptoms worsen. After a while, when the exacerbation ends, the symptoms may improve or persist.
Possible triggers include infections and stress, but there may also be no noticeable trigger.
Anyone who notices a worsening of symptoms or that new symptoms appear should contact a doctor in case they need additional treatment or monitoring.