Even though there is a wide spectrum of possible symptoms, severity, and duration in an MS flare, knowing what causes an exacerbation and what to expect if you have one can help you navigate the unpredictability of the disease. Damage to the myelin and to the underlying axons interrupts or stops the transmission of nerve impulses between the brain and other parts of the body, resulting in the signs and symptoms of MS. Those can include vision loss, balance problems, fatigue, numbness and tingling, and many others, depending on where the damage occurs. Some MS symptoms can be long-lasting or permanent, while other symptoms tend to come and go. When existing symptoms worsen, old symptoms recur, or new symptoms appear, it is called an MS flare or, alternatively, an exacerbation, relapse, or attack. Acute symptom flares are typically followed by periods of months or even years when symptoms subside or completely disappear.
Symptoms of an MS Flare
Symptoms of MS flares vary from person to person. Some common symptoms signaling a flare include the following:
Severe fatigueNumbness and tingling in the arms and legsEye pain or blurred visionWeaknessBalance difficultiesBladder or bowel problems
According to Tanuja Chitnis, MD, an associate professor of neurology and the director of the Partners Pediatric MS Center at Massachusetts General Hospital for Children, in Boston, “Symptoms of an MS flare generally come on over the course of several days."
Causes of a Flare
Flares are caused by inflammation in the central nervous system that damages areas of myelin. Exactly what triggers the inflammation can be difficult to pinpoint, Dr. Chitnis says. “Flares can be triggered by infections, including bladder infections. Some evidence suggests that stress may trigger flares, but this is still controversial,” she says. One misconception is that vaccines increase the risk of an MS flare. “The evidence is strong that vaccinations do not trigger flares,” Chitnis says. RELATED: New Vaccine Guidelines for People With Multiple Sclerosis
Preventing Exacerbations
Though flares cannot be prevented entirely, it’s sometimes possible to avoid the things that may trigger them. For example, since flares can be triggered by infection, it’s important to wash your hands frequently during cold and flu season and to get an annual flu shot, as long as you have no medical reasons not to. Taking steps to lower your risk of urinary tract infections can help, too. These include:
Drinking plenty of water or other fluids to flush out bacteriaUrinating when you feel the urge (rather than waiting)Seeing your doctor for treatment of any ongoing bladder problems, such as urinary incontinence or urinary retention
RELATED: How to Prevent Urinary Tract Infections or UTIs
Duration, Severity, and Recovery
Relapses can last anywhere from a few days to a few weeks or even months, depending on your response to treatment. Sometimes a brief flare-up of symptoms can occur and then resolve without any treatment at all. This is called a pseudoexacerbation and is not technically classified as a relapse. Pseudoexacerbations are usually brought on by increased body temperature and go away when the body cools down, sometimes in a matter of minutes. The severity of flares varies from person to person and from flare to flare. Some research, including a study published in Neurology in 2014, shows that people with higher levels of vitamin D have less severe flares. There’s also evidence to support supplementing with vitamin D to treat insufficiencies. Research published in Multiple Sclerosis and Related Disorders in November 2016 found that participants who took oral vitamin D3 supplements experienced a decrease in the number of relapses. Recovery is also variable. Chitnis says that younger people generally recover better from flares than older people. Poor recovery from flares in the first five years following diagnosis could be a risk factor for developing early secondary-progressive MS, according to a study published in August 2015 in Neurology.
Treatment for MS Flares
Mild flares may not require any treatment, but more severe relapses that affect a person’s ability to function can be treated, usually with high-dose steroid medications, for several days to shorten the duration of the flare.
Steroids
Considered a first-line treatment for exacerbations, steroids reduce inflammation and relieve symptoms, but they do not reverse the damage to the nerves. Steroids are typically given through an IV for three to five days. Depending on the type of relapse and what your doctor recommends, a tapering dose of oral steroids for one to three weeks may follow, according to the National Multiple Sclerosis Society. Recent studies have shown that oral steroids may be a less costly and more convenient way to treat relapses compared with IV delivery. In a retrospective nonrandomized study published in April 2018 in the European Journal of Hospital Pharmacy, for example, oral steroids were just as effective as IV steroids, and 79 percent of patients preferred taking the medication orally.
Plasmapheresis
Plasmapheresis (PMP) can be used as a second-line therapy if a person can’t tolerate steroids or if steroids have been tried and haven’t been effective in treating the relapse. In this medical procedure, also known as apheresis, plasma exchange, or PLEX, whole blood is removed from a large vein and separated into the cellular components and plasma, according to the Neurological Institute at Cleveland Clinic in Ohio. The removed plasma is discarded and replaced with colloid fluid that’s a combination of human serum albumin or fresh frozen plasma, which is then combined back with the cellular components and returned to the patient. A study published in Multiple Sclerosis and Related Disorders in January 2018 found that plasma exchange was relatively safe and effective, with complete recovery in 41.3 percent of patients and partial recovery in 39.1 percent.
Intravenous Immunoglobin
Intravenous immunoglobin (IVIG) can be used to treat relapses, though it is typically considered a second- or third-line treatment. At the Cleveland Clinic’s Mellen Center for Multiple Sclerosis Treatment and Research, IVIG is used only if a person doesn’t respond to or can’t tolerate steroids and plasmapheresis. Immunoglobin is the term for the fraction of plasma that contains antibodies. In IVIG, a mixture of antibodies is delivered intravenously with the aim of treating the relapse by stimulating some parts of the immune system while suppressing other parts.
Acthar Gel
Acthar gel (repository corticotropin injection), another second-line therapy, was found to be a more effective alternative to steroids for treating flares compared with IVIG or plasmapheresis, according to a study published in September 2019 in Neurology and Therapy conducted by Mallinckrodt, the company that manufactures the gel. Acthar stimulates the production of the steroid hormones cortisol, corticosterone, and aldosterone, which help the body respond to stress. In the study, Acthar successfully treated MS relapses in 96.9 percent of patients compared with 50.7 percent for plasmapheresis and 43.9 percent for intravenous immunoglobulin. In an analysis sponsored by Mallinckrodt, Acthar was found to be more cost-effective than PLEX or IVIG, although all three therapies are considerably more expensive than steroid treatment. In a cost per response analysis, Acthar gel cost $141,970 compared with the other therapies, which cost an average of $253,331. These costs don’t factor in medical insurance coverage that would vary from person to person.
The Role of Disease-Modifying MS Drugs in Preventing Relapses
Disease-modifying therapies (DMTs) for MS aren’t used to treat flares, but some of the newer ones show promise at preventing them, says Bruce Bebo Jr., PhD, the executive vice president for research at the National Multiple Sclerosis Society. “Treatments seem to be getting better at decreasing the frequency of flares and the inflammation responsible for them and the damage the flares cause to the body,” Dr. Bebo says. Evidence supports the effectiveness of these medications, including a study that tracked the effectiveness of nine different oral and injectable DMTs, published online in April 2017 in ClinicoEconomics and Outcomes Research. Investigators found that people who were adherent to the medications reduced the likelihood of relapse by 42 percent and hospitalization by 52 percent. A poster presentation at the Consortium of Multiple Sclerosis Centers in June 2019 also found increased incidence of relapses when people stopped taking their disease-modifying therapy for more than two months. That group had nearly 28 percent more relapses, 25 percent more emergency department visits, and 40 percent more hospitalizations compared with people who continued to take their medication.
Recovering From an MS Flare
Some people regain total function after a flare, while in others the recovery may be only partial. A variety of types of rehabilitation specialists — including physical therapists, speech language pathologists, occupational therapists, and cognitive specialists — can play an important role in helping you regain physical and mental function after a flare. Additional reporting by Becky Upham.
