What to do if you are having an MS flare up or relapse

Posted on 4 February 2019 in Managing Relapses

If you think you are having a relapse, your best option is to contact your MS team (MS nurse or neurologist) as soon as possible and ask for advice.

Why?

  • To help in confirming whether this is a relapse and if significant, you might need to consider treatment sooner rather than later.
  • Document your symptoms and to consider whether you need to start or switch your disease modifying therapy (DMT).
  • The MS team has the complex needed skills while other healthcare professionals rarely manage a reasonable number of PwMS to maintain the required expertise. 

Alternatively, you might need to contact your GP or other available healthcare professionals.

MS relapse is also known as exacerbation, attack, an episode, a blip or a flare-up. It causes relatively sudden (over hours or days) new symptoms or worsening of old symptoms. It can be very mild, or severe enough to interfere with a person’s ability to function at home and at work.

It is interesting to note that there is some seasonal variation in the incidence of MS relapses, with the incidence peak in spring and trough in winter!

Source: multiplesclerosis.net/living-with-ms/multiple-sclerosis-relapses/

To be true, a relapse must:

  • last at least 24 hours
  • be separated from the previous attack by at least 30 days
  • there must be no other explanation for the symptoms

The other possible explanations might cause symptoms that simulate an MS relapse, usually referred to as “Pseudo-relapse”, these include:

  • Heat
  • Stress
  • Infection

It is important to recognise a pseudo-relapse as it is not caused by inflammation or worsening of your MS and does not need consideration of immune therapy or alteration to your existing DMT.

Repeated worsening of similar pattern of symptoms (stereotyped) in a PwMS is not a typical feature for MS relapses and raises suspicion of pseudo-relapses.

If you are not sure whether you are having a relapse, one option is to wait 1-2 days to see if your symptoms improve. If you have MS for a while, you are likely had become an expert on your own MS and you have a better feel for whether or not you are having a relapse.

Most relapses last from a few days to several weeks or occasionally months. The good news is that not all relapses require treatment. Mild sensory symptoms or more of fatigue that don’t significantly impact a person’s activities can generally be left to get better on its own.

For moderate and severe relapses like loss of vision, significant weakness or poor balance, it is generally recommended to consider a short course of high-dose corticosteroids to reduce the inflammation and bring the symptoms to an end more quickly.

The most common treatment regimen is a five-day course of oral methylprednisolone; occasionally IV methylprednisolone infusion is recommended for 3-5 days as per NICE MS Guideline.

Your MS team should discuss with you the pros and cons of taking steroids so that you can decide together on the best course of action in your situation. Corticosteroids use for a relapse does not have any long-term benefit on your MS.

It is highly recommended not to use other types of steroids for MS relapses and not to use a course longer than the recommended few days. This practice is still not rare in the UK and abroad!

Rest can be useful during a relapse when fatigue is overwhelming.

Rehabilitation can restore or maintain functions essential to daily living especially immediately after a relapse to help people get back on track. Ask your MS team whether this might be useful to you.

What can I do to reduce my risk of having a relapse?

  • Avoid excessive or prolonged stress and try to manage early
  • Reduce your risk of infections by flu vaccination, for example or by managing your urinary symptoms to avoid recurrent UTIs.
  • Maintain healthy life-style: balanced diet, regular exercise and avoid smoking can also reduce your infections risk
  • Adhere to your DMT if you were missing it previously.
  • Consider DMTs when your MS team advise you and re-consider if you were reluctant to use these medications in the past.

From my personal experience at the Royal Stoke MS Centre in the last few years, we are probably treating a smaller number of relapses and a smaller number of severe relapses than before in spite of increasing size of our MS cohort and better access to our On-Call MS Team. This is probably due to more use of the highly effective DMTs. This is not surprising but needs confirmation by an appropriate study.

Useful sources of further information

  1. MS Trust website: Managing relapses
  2. MS Society website: Managing relapses
  3. BMJ article: Relapse in multiple sclerosis
  4. Systematic review

Dr Adnan Al-Araji, Consultant MS Neurologist