Managing MS Flare-Ups

If you live with multiple sclerosis (MS), you may notice that sometimes symptoms can hit you like a freight train, lasting weeks or even months, while other times you may feel worse for a few hours, then rebound to your normal baseline.

A period of new or worsening MS symptoms that results from new inflammation in the brain, spinal cord, and/or optic nerves is often referred to as a flare-up. It may also be called a relapse, attack, or exacerbation—the terms are generally used interchangeably. Flare-ups occur when your immune system mistakenly attacks the protective covering (called myelin) around nerve fibers in the central nervous system (CNS).

The CNS sends signals to your body to make it function. When multiple sclerosis disrupts those impulses, it gives rise to a wide range of symptoms, says Daniel Gratch, M.D., a neuroimmunologist at Northwell Health’s Lenox Hill Hospital in New York City.

What Is an MS Flare-Up?

“A true MS flare-up is a new symptom or a worsening symptom that lasts more than 24 hours,” explains Dr. Gratch. To identify an MS flare-up, specialists look for symptoms that:

• Are new or significantly more intense than usual
• Occur at least 30 days after the beginning of a previous relapse
• Cannot be explained by fever, infection, or another identifiable trigger

What Does an MS Flare-Up Feel Like?

The specific feeling of a relapse with multiple sclerosis depends on where the MS-triggered inflammation occurs. A lesion on your optic nerve, for example, can cause optic neuritis, a sometimes-painful condition that can affect your vision, while an attack on your corticospinal tract can affect the “conscious, voluntary movement of your limbs,” affecting mobility and your sense of balance, notes Dr. Gratch.

Because every MS relapse comes with a unique set of symptoms, there is no universal experience of what an MS attack feels like, says Daniel Giang, M.D., a neurologist from Loma Linda University in California. Your experience may also differ from one relapse to another, he adds.

Common symptoms from multiple sclerosis include:

• Blurry vision
• Dizziness and vertigo
• Double vision
• Electric-shock-like sensations, a condition known as Lhermitte sign, that occur with certain neck movements, especially bending the neck forward
• Fatigue
• Mood changes
• Muscle weakness
• Numbness and/or tingling
• Partial or complete loss of vision, usually in one eye at a time
• Slurred speech
• Trouble with memory, thinking, and understanding information
• Trouble with sexual, bowel, and bladder function
• Trouble with walking or not being able to walk at all

How an MS Flare-Up Can Affect Walking and Mobility

Walking requires something called proprioception, the body’s ability to sense its own position and movements in space, per the Cleveland Clinic. Multiple sclerosis can disrupt your overall coordination and the functions that help you move, making walking slower, less steady, or more tiring. It can also cause vertigo, muscle weakness, stiffness, spasticity, numbness, and pain, per the National MS Society.

Weakness and other mobility symptoms are common in MS because the corticospinal tract takes up so much real estate in the CNS, says Dr. Gratch. And it doesn’t feel the same for everyone, adds Dr. Giang. You might feel like your legs weigh 100 pounds, making it difficult to move them or climb stairs, or your legs may feel jelly-like, leaving you unable to support yourself, per MS Trust.

Foot drop, a common condition in multiple sclerosis, occurs when the front of the foot doesn’t lift properly when you attempt to walk. Your toes may drag or catch on the ground, upping your risk of tripping and falling.

Walking and mobility issues can feel “totally different if you are weak rather than imbalanced, or [instead] have loss of sensation,” Dr. Giang points out.

You may also find that walking is tougher after you’ve been active for a while or as the day goes on, according to Dr. Gratch. If you notice new weakness, more frequent stumbling, or a change in what you can do comfortably and safely, tell your MS care team.

MS Relapse vs. Pseudo-Relapse

A temporary worsening of your symptoms does not always mean MS inflammation has become active again, Dr. Gratch points out. For instance, 60% to 80% of people living with multiple sclerosis are extra-sensitive to heat. Exposure to too much heat can lead to flaring symptoms, which usually retreat once the core body temperature cools down.

Other triggers, including fever, infection, and stress, can also temporarily cause a spike in symptoms, Dr. Gratch says. These temporary increases are what’s called a pseudo-relapse or pseudo-exacerbation.

During a pseudo-relapse, your symptoms are real, but the flare-up is not caused by a new inflammatory lesion on your brain, spinal cord, or optic nerve. Once you clear the fever or infection or get out of the heat, you’ll likely feel better and return to baseline.

A true MS flare, Dr. Gratch notes, will last days, weeks, or even months, and often requires treatment such as steroids to resolve. Always call your healthcare team when you experience new symptoms, he advises.

Is It an MS Relapse or a Pseudo-Relapse?

What Can Trigger a Temporary MS Flare?

When you put extra stress on your central nervous system or raise your core body temperature, your multiple sclerosis symptoms may temporarily flare. These are common pseudo-relapse triggers:

• Fever or infection. Respiratory infections, influenza, COVID-19, and urinary tract infections (UTIs) can all trigger a temporary flare-up.
• Heat. Hot weather, a hot shower or bath, a sauna, or exercise that raises your core temperature can temporarily worsen your MS symptoms.
• Physical exhaustion. Overexertion or insufficient rest can make symptoms feel more pronounced, both doctors agree.
• Stress and poor sleep. Some recent research suggests that poor sleep due to emotional stress may contribute to MS symptoms flaring.

How Long Does an MS Flare Last?

No two people with multiple sclerosis share identical symptoms or experiences, notes Dr. Giang, and flare-ups follow suit. However, a true flare “takes a few days or weeks to resolve,” says Dr. Gratch. Your symptoms must persist for at least 24 hours, he adds, to meet the clinical definition of a relapse, though most typically last longer. Some symptoms take months to retreat, and some may not resolve completely.

Dr. Giang says that a typical relapse lasts around six weeks, while symptoms from a pseudo-relapse usually resolve once the trigger is removed.

What to Do During a Multiple Sclerosis Flare-Up

With any newly presenting symptoms, call your care team, both doctors advise.

While you wait for guidance, you can practice multiple sclerosis self-care strategies. These may include:

• Keep your core cool. Heat can trigger temporary flares. Make yourself a cool compress from a washcloth soaked in cold water and press it against your neck or chest.
• Identify possible triggers. Are you running a fever? Do you have a UTI? Are you behind on your sleep? Keep track of any surrounding circumstances that might contribute to an MS flare-up, and share this information with your doctors.
• Prioritize rest. Adults should get seven to nine hours of sleep each night, but if you have MS, you may need even more. Give yourself time to recover, particularly if you are ill or exhausted.
• Track your symptoms. Record what symptoms you are experiencing; when they began; whether they are constant or intermittent; and how they affect your daily activities.

How Are MS Relapses Treated?

Your care team will assess whether or not you require medications, says Dr. Gratch. Corticosteroids are often a first line of defense for acute MS relapses. High-dose steroids, such as methylprednisolone, reduce inflammation and can reduce the time it takes for your symptoms to improve, per the Multiple Sclerosis Association of America (MSAA).

Steroids do not guarantee a full recovery. Your doctor will weigh the potential benefits against the risks based on your symptoms and medical history.

Steroids may be given intravenously or by mouth, the MSAA reports. High-dose steroids can cause side effects, including sleep problems, mood changes, stomach upset, and elevated blood glucose. Make sure your care team knows about other medical conditions and medications you take.

For severe relapses or symptoms that do not respond adequately to steroids, specialists may consider additional treatment, such as plasma exchange, per the MSAA. This is not necessary for most relapses.

Your MS care team may also review your long-term disease-modifying therapy, per the National MS Society. These medications aim to reduce MS disease activity and the risk of future relapses. Never stop or change a disease-modifying medication without discussing it with your MS team.

Staying Safe When a Flare Affects Mobility

During an MS attack, walking without losing your balance, rising from a chair, and getting in and out of the shower may become more difficult. There are plenty of assistive devices for MS to help make everyday activities safer and easier to do, including:

• Rollators. A rollator is a wheeled walker, usually equipped with hand brakes and a seat. It provides walking support that allows you to stop and sit when fatigue or weakness strikes.
• Power chairs. A power wheelchair may help when weakness, balance problems, or fatigue make walking unsafe or impractical for some or all activities.
• Shower transfer assistance. A transfer bench can be placed half-in, half-out of the bathtub. Its swiveling seat allows you to sit down, then slide your way into the tub without having to step over anything or stand.

Recovering From an MS Relapse

Recovery requires “a multi-prong approach” that involves more than just taking medication, says Dr. Giang. Depending on your symptoms, this approach might include:

• Physical therapy. You might work with a therapist on building strength, improving how well you walk, and bettering your balance.
• Psychological support. Talking with a therapist, as well as family and friends, is very important, both doctors agree. The National MS Society offers helpful resources to create a strong support system.
• Occupational therapy. An occupational therapist might visit your home to help you make needed modifications, based on your specific symptoms.
• Speech therapy. If you have difficulty speaking or swallowing, you might work with a speech-language pathologist.

Can MS Flare-Ups Be Prevented?

There is no guaranteed way to prevent a relapse. However, by following your MS care plan, including medications and physical therapy, while also incorporating self-care strategies at home, you may be able to lower the frequency or severity of flare-ups.

When Is an MS Flare-Up an Emergency?

When in doubt about sudden or severe flaring symptoms, err on the side of urgent evaluation. Contact your MS care team if:

• You develop new symptoms.
• Existing symptoms become noticeably worse.
• Your symptoms interfere with walking, balance, or everyday activities.

The National MS Society recommends you seek urgent medical attention for:

• Unexplained side effects of your medications.
• Infection.
• Falls.
• Any symptom that could indicate a medical emergency, such as a heart attack or stroke. Call 911.

Remember, don’t wait for symptoms to last 24 hours before seeking medical advice if they are severe or affecting your safety. Your MS care team can help determine whether your symptoms indicate temporary worsening related to heat or infection, a relapse, or some other cause.