How to Spot the Signs of an MS Flare

About 85 percent of people who have multiple sclerosis are first diagnosed with relapsing-remitting MS (RRMS), according to the National Multiple Sclerosis Society (NMSS). This means they have relapses (also called flares, attacks, or exacerbations), or periods where symptoms get worse or new symptoms appear, and remissions, or periods when their symptoms are less severe or disappear.

Some people with secondary-progressive MS, a later stage of RRMS, continue to have relapses, along with a general progression of symptoms and disability.

Is It a Flare or a Pseudoexacerbation?

MS flares occur when inflammation in the central nervous system (brain and spinal cord) causes damage to the myelin sheath that protects the nerve fibers, as well as the underlying nerve fibers.

To be considered a true flare or exacerbation, a relapse must occur at least 30 days after the previous flare, and the new or recurring symptoms must last for at least 24 hours, per the NMSS.

When new or worsened MS symptoms clear up in less than 24 hours, it’s called a pseudo-relapse or pseudoexacerbation. Heat, humidity, overexertion, fatigue, fever, and infections (such as urinary tract infections) can cause pseudoexacerbations, notes the NMSS. Other illnesses, depression, and stress can also cause pseudoexacerbations, according to the Multiple Sclerosis Association of America (MSAA).

While the symptoms of a pseudoexacerbation are real, there is no new damage being done in the central nervous system.

True flares can last anywhere from a few days to a few weeks or months, per the NMSS.

It is not always clear from the outset whether a person is experiencing a flare or a pseudoexacerbation, and sometimes watching and waiting is the only way to know.

But if you experience any new symptom that interferes with your ability to function normally, says Matthew McCoyd, MD, a neurologist at Loyola University Medical Center in Chicago, let your doctor know about it right away.

Symptoms of a Flare

The signs and symptoms of an impending MS flare include virtually any of the possible symptoms caused by MS. They vary from person to person and from flare to flare.

True flares gradually worsen over the course of hours, consist of new "negative symptoms" or loss of function (weakness, vision loss, gait impairment, numbness), and will typically last multiple days. Symptoms that are brief and transient (lasting less than 24 hours) are not consistent with a flare.

Many people begin to recognize certain symptoms that signal that a flare may be coming. “As unpredictable as the disease is, my signs are pretty regular,” says Cathy Chester, a writer in New Jersey who was first diagnosed with relapsing-remitting MS in 1986.

“My feet and sometimes my fingers start tingling, and I begin to feel weak; those are usually the first signs that something is awry,” says Chester. For Chester, numbness and extra fatigue often follow those initial symptoms. “I know at that point that my body is warning me that a flare or a pseudoexacerbation is coming,” she says.

According to the NMSS, signs and symptoms of MS include:

• Increased fatigue
• Tingling or numbness anywhere on the body
• Brain fog, or difficulty thinking
• Muscle spasms
• Depression
• Visual changes, such as blurred vision
• Pain
• Tremor
• Balance problems
• Weakness
• Dizziness
• Bladder changes
• Any combination of these symptoms

When you know how MS usually affects you, monitoring how you feel from day to day can help you catch potential flares early. On the other hand, being overly vigilant can have a negative effect on your mental health.

It’s best — although not easy — to find a way to strike a balance between noticing what’s happening in your body and worrying about every change or sensation.

“When I was first diagnosed, I worried a lot more when I started to get these signals, partly because everything was new,” says Chester. Now that she’s more knowledgeable about life with MS, she adds, it’s become easier to notice symptoms or changes in her body and not overreact or get stressed about them.

It’s also important to consider other possible causes of your symptoms; they may have nothing to do with MS, but they may still need to be checked out by a medical professional.

How to Treat an MS Relapse

Not all flares require treatment. Mild sensory changes or episodes of fatigue that don’t significantly impact your daily life can usually be left to get better on their own, notes the NMSS.

Severe MS flares are usually treated with a short course of high-dose corticosteroids, most commonly administered intravenously or orally over three to five days.

Steroids reduce inflammation and speed recovery from the relapse, but they don’t correct the damage to the nervous system.

For people who can’t tolerate or don’t respond to steroids, there are other treatment options. These include:

• H.P. Acthar Gel, a highly purified preparation of adrenocorticotropic hormone (ACTH) in a gel. ACTH stimulates the adrenal cortex gland to secrete cortisol, corticosterone, and aldosterone, per the NMSS.
• Plasmapheresis (plasma exchange). This exchange, also referred to as a “blood-cleansing procedure,” may be helpful for people experiencing an MS relapse who have not adequately responded to corticosteroids, according to the NMSS.
• Rehabilitation. Various forms of rehabilitation can help restore physical and mental functioning that’s been affected by an MS flare.

Can MS Relapses Be Prevented?

MS flares may not be completely preventable, but the newer disease-modifying medications for MS have been shown to reduce the frequency and severity relapses, per the NMSS. It can take a few tries to find the drug that works best for you.

Aside from medication, remaining calm and adopting a positive attitude whenever possible can help prevent a flare from coming on, says Chester. “Keeping your stress level at a minimum and taking care of yourself really does help,” she says. “Listen to your body and reach out for support from friends and family. If you need something, ask,” she adds.

Here are some common MS symptoms and a few self-care tips to manage them.

Have a plan to head off fatigue. MS fatigue is not like normal fatigue. It can be so severe that it's disabling. But “good sleep habits, avoiding caffeine and too much alcohol, and getting some daily exercise are good ways to prevent MS fatigue,” says Dr. McCoyd. There are also medicines that help fight MS fatigue.

Find workarounds for brain fog. Slowed thinking, confusion, and difficulty concentrating are frequent but under-recognized MS symptoms. “It can be infuriating for me, because I’m a writer,” says Chester. “I have issues finding the right word that I want to use, or I can’t remember facts that I know by heart,” she says. Two strategies that can help you stay focused and remember things better are to avoid multitasking and to write things down. Cognitive rehabilitation can also help.

Get help for painful symptoms. Chester had MS for more than 30 years before she experienced spasticity. “I have spasms in my feet, my calves, and my hands, and it comes and goes,” she says. “It’s a strange feeling to watch your toes and fingers have a mind of their own,” she adds.

“It can be very painful; I didn’t want to add another medication, and so I use deep breathing and meditation to help with the pain,” says Chester. On the suggestion of her neurologist, Chester also began to drink water with electrolytes, and that’s helped, she says.

Take depression seriously. “Depression is common in MS and often goes unrecognized,” McCoyd says. “It is important for people with MS to have lots of support, exercise regularly, and use stress-reduction techniques like yoga or meditation to combat this MS symptom.” Seeking help from a mental health professional is also important when depression persists in spite of self-care efforts.

Additional reporting by Becky Upham.