Multiple Sclerosis (MS)

	Topic Overview
	Health Tools
	Cause
	Symptoms
	What Happens
	What Increases Your Risk
	When To Call a Doctor
	Exams and Tests
	Treatment Overview
	Prevention
	Home Treatment
	Medications
	Surgery
	Other Treatment
	References
	Credits

What is multiple sclerosis?

Multiple sclerosis, often called MS, is a disease that affects the central nervous system—the brain and spinal cord. It can cause problems with muscle control and strength, vision, balance, feeling, and thinking.

Your nerve cells have a protective covering called myelin. Without myelin, the brain and spinal cord can't communicate with the nerves in the rest of the body. MS gradually destroys myelin in patches throughout the brain and spinal cord, causing muscle weakness and other symptoms. These patches of damage are called lesions.

MS is different for each person. You may go through life with only minor problems. Or you may become seriously disabled. Most people are somewhere in between. Generally, MS follows one of four courses:

• Relapsing-remitting, where symptoms fade and then return off and on for many years.
• Secondary progressive, which at first follows a relapsing-remitting course and then becomes progressive. “Progressive” means it steadily gets worse.
• Primary progressive, where the disease is progressive from the start.
• Progressive relapsing, where the symptoms come and go but nerve damage steadily gets worse.

Whatever your symptoms are, treatment and self-care can help you maintain your quality of life. There is no cure for MS, but it is not fatal except in rare cases.

What causes MS?

The exact cause is unknown, but most experts believe MS is an autoimmune disease. In this kind of disease, the body’s defenses, called the immune system, mistakenly attack normal tissues. In MS, the immune system attacks the central nervous system—the brain and spinal cord .

Experts don't know why MS happens to some people but not others. There may be a genetic link, because the disease seems to run in families. Where you grew up may also play a role. MS is more common in those who grew up in colder regions that are farther away from the equator.

What are the symptoms?

Symptoms depend on which parts of the brain and spinal cord are damaged and how bad the damage is. Early symptoms may include:

• Muscle problems—You may feel weak and stiff, and your limbs may feel heavy. You may drag your leg when you walk. You may drop things more than usual and be less coordinated.
• Visual problems—Your vision may be blurred or hazy. You may have eyeball pain (especially with movement), blindness, or double vision. Optic neuritis (a sudden loss of vision and eye pain) is a fairly common first symptom.
• Sensory problems—You may feel tingling, a pins-and-needles sensation, or numbness. You may feel a band of tightness around your trunk or limbs or a feeling of electricity moving down your back and limbs.
• Balance problems—You may feel lightheaded or dizzy or feel like you're spinning.

As MS gets worse, you may have tremors and pain and feel stiff when you move. You may have problems with controlling urination, swallowing, and thinking clearly. MS can lead to depression.

Many people with MS are sensitive to heat. Hot temperatures, a fever, a hot shower, or too much exercise can make their symptoms worse until they cool down.

MS is very unpredictable. Your symptoms may suddenly get worse with no warning, or you may go for years without any problems.

How is MS diagnosed?

Diagnosing MS is not always easy. The first symptoms may be vague, and many of the symptoms can be caused by problems other than MS. Try not to be frustrated if months or even years go by before your illness is definitely identified as MS.

MS is not diagnosed unless a doctor can be sure that you have had at least two attacks. The doctor will examine you, ask you questions about your symptoms, and do some tests. An MRI is often used to confirm the diagnosis, because the patches of damage (lesions) caused by MS attacks can be seen with this test.

How is it treated?

Three kinds of medicines are used to treat the disease. They are used:

• During a relapse, to make the attack shorter and less severe.
• Over a long period of time, to keep down the number of attacks and how severe they are (disease-modifying therapy). This treatment may delay or at least reduce the damage MS does to the body.
• To control specific symptoms—like fatigue, depression, urinary problems, sexual difficulties, pain, or muscle stiffness.

You may find it hard to decide whether to take any of the drugs that slow the progression of MS, especially if your symptoms have been mild. The drugs do not work for everyone, and they often have strong side effects. But experts say it’s usually best to start taking medicine as soon as you are diagnosed, because damage may be going on even if you don't have symptoms. You and your doctor will decide whether you should try any of these drugs.

Physical therapy, occupational therapy, and speech therapy can help you reduce some physical problems caused by MS. You can also help yourself at home by eating right, getting regular exercise and rest, and learning to use your energy wisely.

Dealing with the physical and emotional demands of MS is not easy. If you feel overwhelmed, talk to your doctor. You may be depressed, which can be treated. And finding a support group where you can talk to other people with MS can be very helpful.

Frequently Asked Questions

Health tools help you make wise health decisions or take action to improve your health.

	Decision Points focus on key medical care decisions that are important to many health problems.
	Should I have disease-modifying therapy for multiple sclerosis?
	Actionsets are designed to help people take an active role in managing a health condition.
	Rehabilitation for multiple sclerosis

The cause of multiple sclerosis (MS) is unknown. Because a person's risk of MS is slightly higher when a relative (especially a parent, sister, or brother) has MS, there may be a genetic link.

The unusual relationship between a person's geographic location during childhood and the risk of MS later in life suggests that there may be environmental factors at work in the disease—such as viral illnesses or other infectious diseases. However, there is no clear proof that any specific infection causes MS. Other triggers for MS have been proposed, but none have yet been proven.

Furthermore, a childhood viral illness or other environmental factor by itself is probably not enough to explain why some people later develop MS. Research is beginning to suggest that a problem with the body's natural defenses (immune system) occurring early in life or after infections may trigger the onset of MS. The “trigger” may be an autoimmune reaction in which the immune system attacks myelin, the coating that protects nerve fibers.

The symptoms of multiple sclerosis (MS) vary from person to person depending upon which parts of the brain or spinal cord (central nervous system) are damaged. The loss of myelin and scarring caused by MS can affect any part of the central nervous system.

Symptoms may come and go or become more or less severe from day to day or, rarely, from hour to hour. Symptoms may become more severe with increased (or, less commonly, decreased) body temperature or after a viral infection. Symptoms of MS, such as spasticity tremors, pain, and difficulty thinking clearly, are similar to those of many other conditions and do not necessarily mean you have MS.

Early symptoms

Common early symptoms of MS include:¹

• Muscle or motor symptoms, such as weakness, leg dragging, stiffness, a tendency to drop things, a feeling of heaviness, clumsiness, or a lack of coordination (ataxia).
• Visual symptoms, such as blurred, foggy, or hazy vision, eyeball pain (especially with movement), blindness, or double vision. Optic neuritis—a sudden loss of vision and eye pain—is a fairly common first symptom, occurring in up to 25% of those who develop MS.
• Sensory symptoms, such as tingling, a pins-and-needles sensation, numbness, a bandlike tightness around the trunk or legs, or electrical sensations moving down the back and legs.

Less common early symptoms include:¹

• Balance symptoms, such as lightheadedness or dizziness, and a spinning feeling (vertigo).
• Bladder symptoms, such as an inability to hold urine (urinary incontinence) or to completely empty the bladder, or a loss of bladder sensation—an inability to sense that the bladder becoming full until there is a sudden, urgent need to urinate.

Advanced symptoms

As MS progresses, symptoms may become more severe and may include:

• Increased muscle problems, such as weakness, leg dragging, clumsiness, or lack of coordination.
• Stiff, mechanical movements (spasticity) or uncontrollable shaking (tremor), which may make walking difficult. A wheelchair may be needed some or all of the time.
• Pain and other sensory symptoms.
• Incontinence or, less often, an inability to urinate (urinary retention).
• Constipation and other bowel disorders.
• Male erectile dysfunction (impotence) and female sexual dysfunction.
• Cognitive and emotional problems, which are common in people who have had MS for some time.
• Cognitive problems, such as memory loss, difficulty concentrating, reduced attention span, or difficulty finding the correct words.
• Emotional symptoms, such as depression, anxiety, and anger. A rare symptom is excessive cheerfulness that seems inappropriate.
• Feeling very tired (fatigue). This can be worse if symptoms such as pain, spasticity, bladder problems, anxiety, or depression make it difficult to sleep.

Generally, MS follows one of four courses:

• Relapsing-remitting, where symptoms may fade and then recur at random for many years. The disease does not advance during the remissions.
• Secondary progressive, which initially follows a relapsing-remitting course. Later on, it becomes steadily progressive.
• Primary progressive, where the disease is progressive from the start. This course of MS can be devastating.
• Progressive relapsing, where steady deterioration of nerve function begins when symptoms first appear. Symptoms appear and disappear, but nerve damage continues. Few people have this course of MS.

Many people with MS do not follow one of these patterns exactly. The course is often hard to predict. Not only does it vary from person to person, but the pattern may change in an individual over time. MS may be more severe in men than women, particularly in middle-aged men who develop the disease.

MS usually progresses with a series of relapses that occur over many years (relapsing-remitting MS). In many people the first MS attack involves just a single symptom. It may be weeks, months, or years before you have a relapse. As time goes by, symptoms may linger after each relapse so you lose the ability to fully recover from the relapse. New symptoms often develop as the disease damages other areas of the brain or spinal cord .

Events that can indicate you may have a more severe progression of MS include:

• Frequent relapses during the first few years of the disease.
• Incomplete recovery between attacks.
• Early, lasting motor problems that affect movement.
• Many lesions that show up on an MRI early in the disease.

The duration of the disease varies. Most people who get MS live with it for decades. While people with MS often become disabled over time, the disease itself is rarely life-threatening and may not directly reduce your natural life span.

The majority of people who develop MS have a relapsing-remitting course; after about 10 years, approximately half of these people develop secondary progressive MS.

Some people have a few mild attacks from which they recover entirely. This is called benign MS.

Although rare, a small number of people die within several months of the onset of MS. This is called malignant or fulminant MS.

Pregnancy and MS

Since most people diagnosed with MS are women in their child-bearing years, questions about having children are common. Research shows that most couples in which one partner has MS are able to have children without MS affecting the pregnancy, labor, or delivery. Plus, MS does not increase the risk of miscarriage, birth defects, or low birth weight. Some women have fewer MS symptoms during pregnancy, then a temporary relapse after delivery. But pregnancy, delivering a baby, and early motherhood do not increase the risk of being disabled by MS over time.^{2, 3}

People with MS who want to have children should talk to their doctor before trying to become pregnant and should consider the following:

• Men with MS may need help to overcome erectile or ejaculatory problems.
• Some medicines used to treat MS should not be used during pregnancy, and some should not be used during breast-feeding. If you are taking medicine for MS, use reliable birth control until you decide to try to become pregnant. Talk to your doctor about when to stop taking the medicine. In some cases, your doctor may suggest that you wait to start trying to get pregnant until a relapse has ended and you are not taking medicine.
• Some symptoms common in pregnancy and after the baby's birth can be made worse by MS. These include depression and fatigue. Plan for any help you may need to manage your work, household, and other children during pregnancy and for the first few months after the baby is born.
• The baby may be slightly more likely to develop MS later in life than a child born to parents who do not have MS.²
• Think clearly, and talk with your partner and doctor about the future. Some people with MS become disabled over time. Because of this, some couples decide not to have children or to have fewer children than they might have otherwise. Other couples don't change their plans for a family once they learn about MS.
• Find an obstetrician to care for you through your pregnancy and delivery who is willing to work closely with the doctor who helps you manage your MS. Because fatigue, depression, and medication use during breast-feeding are all issues to think about after the baby is born, you may also want the pediatrician you choose for your baby to be aware of your MS.

Complications of MS

Complications that may result from MS include:

• Urinary tract infections (UTIs). People with MS often have bladder problems, such as the inability to control or release urine. These problems increase the risk of UTIs.
• Constipation. Weakness and spasms in the bowel and a low level of physical activity are common in people with MS and can lead to constipation.
• Pressure sores. These can develop when a person has to sit or lie in bed for long periods of time, especially if the person is unable to change positions.
• Reduced ability to move and walk, which makes it necessary to use a wheelchair some or all of the time.

MS should not interfere with most routine health care procedures, such as dental anesthesia, general anesthesia (except if you have respiratory problems), and vaccinations, including flu shots. However, it is not clear whether the nasal spray flu vaccine (flu mist) is safe to use when you have MS. The nasal spray vaccine should not be used by people who are taking medicines that suppress the immune system (immunosuppressants), such as mitoxantrone, cyclophosphamide, or methotrexate; people who have problems with their immune systems; or people with long-term health problems.

If you are thinking about donating blood, talk to your doctor about whether it is safe for you to give blood, and about local blood donation guidelines.

Because MS may affect the ability to move and walk, it can place limits on your daily living, particularly as you age. Many people with MS have some disability, but it is not always severe or constant. On average, people diagnosed with MS live another 30 years or more. A few people have a severe course of MS and die earlier.

If you or someone in your family has MS, talk to your doctor about how MS may affect daily living. Knowing what to expect will help you plan for the future.

Your risk of developing multiple sclerosis (MS) increases with:⁴

• Geographic location, or where you lived during childhood (up to age 15). People who spend the first 15 years of their lives in colder climates that are further away from the equator tend to be more likely to develop MS than people who lived closer to the equator during those years.
• Family history of MS. People who have a parent or sibling (including an identical twin) with MS are at slightly higher risk of developing the disease.
• Race. People of Western European ancestry are more likely to develop MS. It is uncommon in Native Americans (American Indians), Eskimos, and Africans.
• Gender. MS is about three times as common in women as in men.

Some of the symptoms of multiple sclerosis (MS) are similar to those of many other illnesses. See your doctor if over a period of time you have more than one symptom, such as:

• Blurry, foggy, or hazy vision, eyeball pain, loss of vision, or double vision.
• A feeling of heaviness or weakness, involuntary leg dragging, stiffness, walking problems, and clumsiness.
• Tingling or a pins-and-needles sensation, numbness, tightness in a band around the trunk, arms, or legs, or electric shock sensations moving down the back, arms, or legs.
• Inability to hold urine or to completely empty the bladder.
• Dizziness and unsteadiness.
• Problems with memory, attention span, finding the right words for what you mean, and daily problem-solving.

If you have been diagnosed with MS, see your doctor if:

• Your attacks become more frequent or severe.
• You begin having a symptom that you have not had before or you notice a significant change in symptoms that are already present.

Watchful Waiting

Milder MS-type symptoms can be caused by many other conditions or periodically occur in healthy people. For example, lots of people experience minor numbness in their fingers or a mild dizzy spell once in a while. Stiffness and muscle weakness can result from being more active than usual. Watchful waiting is appropriate for these types of everyday aches and pains, so long as they do not continue.

If your symptoms become more frequent or do not go away, talk to your doctor.

For people with MS

Talk to your doctor about what to expect from the disease and from treatment. MS is an unpredictable disease, but you probably can get some idea of what is “normal” and what symptoms or problems are reasons for concern.

Some people with MS want active, regular support from their doctors. Others want to manage their condition on their own as much as possible. Wherever you are in this range, find out which signs or symptoms mean that you need to see your doctor, and seek help when you need it.

Who To See

Health professionals who may be involved in evaluating symptoms of multiple sclerosis and treating the condition include:

• Family doctors or internists. Consult your doctor when symptoms first develop. He or she will refer you to a neurologist if necessary. If you have MS, your family doctor or internist can treat your general health problems even if you see a neurologist for MS treatment.
• Neurologists. A neurologist can decide whether your symptoms are caused by MS and can help you decide what may be the best treatment for your condition.

Many university medical centers and large hospitals have MS clinics or centers staffed by neurologists and other health professionals who specialize in diagnosing and treating MS and may be able to provide the most thorough evaluation.

If you have been diagnosed with MS, at some point you may need to seek the help of:

• A physical therapist, to assist with exercise to maintain body strength and flexibility and deal with movement problems.
• An occupational therapist, to identify ways of accomplishing daily activities if MS has caused any physical limitations.
• A speech-language pathologist, to improve speech, chewing, and breathing if MS has affected the muscles of the face and throat.
• A physiatrist. A physiatrist can help with managing pain, maintaining strength, and adapting to physical disability.
• A psychologist or psychiatrist, to evaluate and treat depression, anxiety or other mood disorders, and problems with memory and concentration if these develop.
• A pain management specialist, to help with any significant chronic pain that MS causes in some people. A pain specialist, often as part of a pain clinic, can help find ways of reducing pain when possible and dealing with pain that doesn't go away.
• A neurosurgeon, to perform surgery for severe tremors or spasticity.

To prepare for your appointment, see the topic Making the Most of Your Appointment.

Diagnosing multiple sclerosis (MS) is not always easy. It may take some time from when symptoms first appear to confirm the diagnosis. MS is diagnosed when it is clear from neurological tests and a neurological examination that lesions are present in more than one area of the central nervous system (usually the brain, spinal cord, or the nerves to the eyes) and that damage has occurred at more than one point in time.

A diagnosis of MS is confirmed when you have a combination of:^{5, 6}

1. Two separate episodes of neurological symptoms—such as weakness or clumsiness, vision problems, tingling or numbness, or balance problems—that a neurologist can verify. Each episode must have lasted at least 24 hours and occurred at different times at least 1 month apart.
2. Symptoms that indicate injury to more than one part of the central nervous system, and MRI and laboratory tests that show abnormal findings consistent with a diagnosis of MS.
3. No other disease or condition that is clearly causing the symptoms and test results.

Your medical history and neurological examination can identify possible nervous system problems and are often enough to strongly suggest a diagnosis of MS. Tests may help confirm or rule out the diagnosis when your history and examination alone do not provide clear evidence of the disease.

Some people have had only one episode of a neurological symptom such as optic neuritis, but MRI tests suggest they may have MS. This is known as a clinically isolated syndrome. Many of these people go on to develop MS over time. MS is diagnosed when MRI tests done a few months apart show more than one area of neurological damage and when other tests are consistent with MS.

Tests used to diagnose MS

Magnetic resonance imaging (MRI) of the brain and spinal cord is done to confirm a diagnosis and help your doctor decide which treatment is best. More than 90% of people who have MS have an abnormal MRI result.⁷ For people in whom MS has already been diagnosed, MRI scans may also be used to follow the progression of the disease. MRI and neurologic examination may help doctors predict which people will develop MS after a first attack of symptoms.⁸ See an illustration of an MRI showing MS in the brain .

Lumbar puncture (sometimes called a spinal tap) may be done to evaluate cerebrospinal fluid. Most people with MS have abnormal results on this test, such as abnormal levels of a protein called immunoglobulin G (IgG) or a mild increase in white blood cells.

Evoked potential testing can often reveal abnormalities in the brain and spinal cord and in the optic nerves that a neurological exam and other tests may not be able to detect.

Tests used to diagnose accompanying conditions

Urinary tract tests may be needed to help diagnose a problem with bladder control in a person who has MS.

Neuropsychological tests may be needed to identify thinking or emotional problems, which may be present without the person being aware of them. Typically, these tests are in a question-and-answer format.

Treatment can make living with multiple sclerosis (MS) easier. Your type of treatment will depend on the severity of your symptoms and whether your disease is active or in remission.

Initial treatment

In an attempt to slow down the progression of multiple sclerosis (MS), treatment with medication is recommended as soon as MS has been diagnosed. Findings from clinical studies indicate that people treated soon after being diagnosed with MS have better results than those who delay treatment. Permanent damage to the nervous system may occur in the initial stages of the disease. Early treatment may help prevent or delay some of this damage.

Three types of medications that can reduce the frequency of relapses and possibly slow down the progression of MS have been approved. These are called disease-modifying therapies, and the medications include:⁹

• Interferon beta (Avonex, Betaseron, and Rebif).
• Glatiramer acetate (Copaxone).
• Mitoxantrone (Novantrone).

Interferon beta and glatiramer acetate suppress or alter the activity of the immune system.

Although these medications do not cure MS, they may reduce the overall number, frequency, and severity of relapses in some people who have the relapsing-remitting MS. They may also reduce or delay disability with this type of MS. Betaseron and Novantrone may slow disease progression in some people with secondary progressive MS.

If you decide not to try disease-modifying therapy at this time, you can work with your doctor to regularly evaluate whether the disease is progressing. For more information on this decision, see:

Should I have disease-modifying therapy for MS?

Physical therapy, occupational therapy, and nonmedical treatment done at home can help you manage symptoms and adjust to living and working situations. For more information, see:

Rehabilitation for MS.

Ongoing treatment

If you have been diagnosed with multiple sclerosis (MS), you may need to take interferon beta or glatiramer indefinitely.

Three types of medications—called disease-modifying therapy—have been approved for treating MS. They are:

• Interferon beta (Avonex, Betaseron, and Rebif).
• Glatiramer acetate (Copaxone).
• Mitoxantrone (Novantrone).

These medications suppress or alter the activity of the immune system. Evidence suggests that MS is an autoimmune disease, a disease in which the immune system attacks normal body tissue. In this case, the myelin coating surrounding nerve fibers is attacked by the immune system.

You also can take other medication during attacks or relapses. Corticosteroids are commonly used to shorten relapse time and may limit its severity. However, corticosteroids do not prevent permanent disability from MS and have not been shown to delay or prevent the progression of the disease.

If you are not taking disease-modifying therapy at this time, you can continue to work with your doctor to regularly evaluate the disease's progress. If new lesions develop or existing lesions grow, you may want to reconsider your decision and begin treatment. For more information, see:

Should I have disease-modifying therapy for MS?

You and your health professional will set up a schedule of periodic appointments to monitor and treat your symptoms and follow the progress of your MS. Monitoring your condition helps your doctor determine whether you may need to try a different treatment.

Physical therapy, occupational therapy, and nonmedical treatment done at home can help you manage symptoms and adjust to living and working situations. For more information, see:

Rehabilitation for MS.

Treatment if the condition gets worse

Medications should relieve symptoms that cause discomfort and disability from multiple sclerosis (MS). Symptoms such as spasticity (stiff, tight muscles), pain, fatigue, tremor, depression, sexual difficulties, and bladder problems often respond well to medications.

Physical therapy, occupational therapy, and nonmedical treatment done at home may also help you manage symptoms and adjust to living and working situations. For more information, see:

Rehabilitation for MS.

What To Think About

Findings from clinical trials indicate that people treated soon after being diagnosed with MS have better results than those who delay treatment.

Still, taking the medication has several significant drawbacks. The decision is a difficult one for many people with MS. Some wait to see whether their symptoms get worse before they make a decision to start therapy. A small percentage of people diagnosed with MS may never have more than a few mild episodes and never develop any disability, but there is no way to know yet who will fall into this group.

End-of-life issues

In rare cases, multiple sclerosis (MS) is life-threatening. If your condition worsens considerably, you may want to consider making a living will, which allows your wishes to be carried out if you are not able to make decisions for yourself. For more information, see the topic Care at the End of Life.

Generally, there is no way to prevent multiple sclerosis (MS) or its attacks. For people with relapsing-remitting MS, treatment with interferon beta or glatiramer acetate may reduce the frequency of relapses, and interferon beta may delay disability. Interferon beta-1b (Betaseron) or mitoxantrone (Novantrone) may delay the progression of the disease for some people with secondary progressive MS. Around half of people with relapsing-remitting MS will progress to secondary progressive MS within 10 years.

Claims have been made that MS may be brought on by injury, shock, pregnancy, or vaccinations, but there is no scientific evidence to prove these claims. If you already have MS, a viral infection (such as the flu) may trigger a relapse. During pregnancy, women with MS often have fewer relapses. In the first few months after delivery, however, they may temporarily have more relapses.²

If you have MS, avoid overheating your body whenever possible. Increased body temperature can temporarily make your symptoms worse by causing the nerves already affected by MS to function even more poorly. Use an air conditioner, keep your home somewhat cool, and avoid hot swimming pools and hot tubs. During warm or hot weather, exercise in an air-conditioned area rather than outdoors.

If you have multiple sclerosis (MS), it is important to find ways of coping with the practical and emotional demands of the disease. These are different for everyone, so home treatment varies from person to person.

Home treatment may involve making it easier to get around your home, dealing with depression, handling specific symptoms, and getting support from your family and friends.

• Modify your home or make adjustments to your work situation. It also may help to adjust your daily schedule so that your routine is less stressful or tiring. Excessive fatigue is a common problem for people with MS.
• Follow the food guide pyramid and eat plenty of fruits, vegetables, grains, cereals, legumes, poultry, fish, lean meats, and low-fat dairy products. A balanced diet for a person who has MS is the same as that recommended for most healthy adults.
• Get regular exercise, either on your own or with the help of a physical therapist. If you want to exercise on your own, ask your doctor or a physical therapist to recommend appropriate exercises.
• Deal with urination problems. At some time, most people with MS have bladder problems that can involve difficulty retaining or releasing urine, or a combination of both. Your doctor may prescribe a medication to help you. It may also help to plan your fluid intake and activities so that a toilet will be available when you need to urinate.
• Change how and what you eat if you are having problems swallowing, a common problem with advanced MS.
  • Thicker drinks make swallowing easier. Try milk shakes or juices in gelatin form.
  • Avoid foods such as crackers or cakes that crumble easily. These can cause choking.
  • Soft foods need less chewing. Use a blender to prepare food for easiest chewing.
  • Eat frequent, small meals to avoid fatigue from eating heavy meals.

Physical therapy, occupational therapy, and nonmedical treatment done at home may also help you manage symptoms and adjust to living and working situations. For more information, see:

Rehabilitation for MS.

Make all efforts to preserve your health. Proper diet, rest, wise use of energy, and practical and emotional support from your family, friends, and doctor can all be very helpful.

For more advice about coping with MS at home, contact the National Multiple Sclerosis Society at http://www.nationalmssociety.org.

Medications for multiple sclerosis (MS) may be used:

• During a relapse, to make the attack shorter and less severe.
• Over a long period of time, to alter the natural course of the disease (disease-modifying therapy).
• To control specific symptoms as they occur.

Controlling a relapse

Medications can shorten a sudden relapse and help you recover more quickly. Temporary treatment with medications called corticosteroids is the most common treatment used to control a relapse. These medications have not been shown to affect the long-term course of the disease or to prevent disability.

Altering the course of MS using disease-modifying treatment

Strong evidence suggests that MS is caused by the immune system causing inflammation and attacking the myelin—the coating surrounding the nerve and nerve fibers. Medications that change the activity of the immune system can reduce the number and severity of attacks that damage the protective myelin.

Currently, interferon beta (Avonex and Rebif, and Betaseron), glatiramer acetate (Copaxone), and mitoxantrone (Novantrone) are the only medications that have been approved for this purpose. For people with relapsing-remitting MS, these medications can reduce the number and severity of relapses and can result in fewer brain lesions. They may also delay disability in some people. Betaseron and Novantrone may delay disease progression in some people with secondary progressive MS.

Currently, there is no effective disease-modifying treatment for primary progressive MS.

Relieving symptoms

Treating specific symptoms can be effective, even if it does not stop the progression of the disease. Symptoms that can often be controlled or relieved with medication include:

• Fatigue. Medications to reduce fatigue or help you sleep better may include amantadine (Symmetrel), modafinil (Provigil), or fluoxetine (Prozac).
• Muscle stiffness (spasticity) and tremors. Medications that may reduce muscles spasms or stiffness include baclofen (Lioresal), tizanidine (Zanaflex), dantrolene (Dantrium), gabapentin (Neurontin), diazepam (Valium), or clonazepam (Klonopin). Sometimes a combination of these medications works best to reduce your muscle symptoms.
• Urinary problems and constipation. Medications used to reduce frequent urination may include propantheline (Pro-Banthine), oxybutynin (Ditropan), or tolterodine (Detrol). Medications sometimes used to relieve constipation include bulk agents such as psyllium (Metamucil) or daily use of laxatives.
• Pain and abnormal sensations. Depending on the severity of the pain, both prescription and nonprescription medications may be tried. Prescription medications commonly used to reduce pain associated with MS include baclofen (Lioresal), carbamazepine (Tegretol), or gabapentin (Neurontin). Nonprescription medications may include acetaminophen, ibuprofen, or naproxen sodium.
• Depression. Antidepressant medications may be used to reduce depression that often occurs as a result of having MS. Antidepressants often tried include tricyclic antidepressants—such as amitriptyline (Elavil), desipramine (Norpramin), or imipramine (Tofranil)—or selective serotonin reuptake inhibitors (SSRIs)—such as fluoxetine (Prozac) or sertraline (Zoloft) among others.
• Sexual difficulties. Medications used to relieve sexual difficulties that can be associated with MS include sildenafil (Viagra) for both men and women. Yohimbine and clomipramine may also be given to improve erectile dysfunction.

MS can affect many parts of the nervous system and produce a wide range of symptoms. The choice of medications depends on your symptoms. Medication may be used only some of the time or regularly, depending on how severe or constant a particular symptom is. Changes in diet, schedule, exercise, and other habits can also help manage some of these symptoms. See the Home Treatment section of this topic.

Medication Choices

Symptom management

Medications used to treat symptoms of an attack of multiple sclerosis (MS) and help you recover more quickly from a relapse include:

• Corticosteroids (such as methylprednisolone).
• ACTH (adrenocorticotropic hormone).
• Intravenous immunoglobulin (IVIG) or plasma exchange (neither is used frequently).

Relapsing-remitting MS

Medications used specifically for relapsing-remitting MS to reduce the number and severity of relapses and possibly delay disability include:

• Interferon beta (Avonex, Rebif, and Betaseron).
• Glatiramer acetate (Copaxone).
• Mitoxantrone (Novantrone) for relapsing-remitting MS that is rapidly getting worse.
• Natalizumab (Tysabri). This drug is now available, on a limited basis, for treating relapsing forms of MS. Talk to your doctor to learn more about natalizumab.

Secondary-progressive MS

Medications used to treat and possibly delay the progression of secondary progressive MS that is also relapsing include:

• Interferon beta-1b (such as Betaseron).
• Mitoxantrone (Novantrone).

Primary-progressive MS

No medicines have been clearly proven to help, and none have been approved for primary-progressive MS. Some of the newer and experimental medications, such as immunosuppressants and other medications and biological chemicals (derived from or identical to substances produced by the body) are being tested for primary-progressive MS.

Medications being studied

A variety of immunosuppressants and other medications and biological chemicals (derived from or identical to substances produced by the body) have been tried as therapy for MS. While none have been clearly proven beneficial and none have been approved for treatment of MS, these medications may be used when standard therapy fails.

Several medicines are currently being tested in clinical trials. People with MS who have not responded to standard therapy sometimes choose to participate in these trials. To learn more about clinical trials, talk to your doctor or contact the National Multiple Sclerosis Society at http://www.nationalmssociety.org.

What To Think About

Long-term treatment with interferon beta and glatiramer acetate can improve the quality of life for some people who have relapsing-remitting MS by making relapses less frequent and less severe. Some evidence suggests that these medications may also reduce or delay future disability caused by this form of the disease.

The National Multiple Sclerosis Society recommends that treatment with interferon beta or glatiramer acetate be started as soon as it is clear that you have MS. Most neurologists support this recommendation and now agree that permanent damage to the nervous system may occur early on, even while symptoms are still quite mild. Early treatment may help prevent or delay some of this damage. In general, treatment is recommended until it no longer provides a clear benefit.

Despite the recommendation, however, some people find it difficult to decide whether to begin disease-modifying therapy, especially when their symptoms have been fairly mild. Some may not want to bear the risks and flu-like side effects of interferon therapy when they are not sure they need it. Some may want to see whether their disease worsens before starting therapy. A small percentage of people diagnosed with MS may never have more than a few mild episodes and may never develop any disability, but the disease is unpredictable. For more information, see:

Should I have disease-modifying therapy for MS?

If you decide not to try disease-modifying therapy at this time, work with your doctor to monitor your health through regular checkups and periodic MRI scans to evaluate whether the disease is progressing. If new lesions are developing or existing lesions are growing, you may want to reconsider your decision and begin treatment.

Treating symptoms and relapses

The need and desire for medication vary. If your symptoms are mild, you may choose to manage them without any medication. If you have specific symptoms that are causing problems, certain medications may help you keep them under control. Or you may want to use medication only during a relapse.

You may also want to consider:

• The possible side effects of using steroids or other medications to treat symptoms or control a relapse. Some people have only minor side effects, but others may have side effects that concern them more than their MS symptoms.
• The costs of treating symptoms and controlling relapses. In some cases, using medication to control symptoms and relapses may reduce the need for hospital stays.
• Other personal issues that you face at work or at home.

Also keep in mind that it can be hard to tell whether medication is helping. Multiple sclerosis is a disease with spontaneous remissions, which means that your condition can improve on its own, without any treatment. Just because your symptoms improve after treatment does not mean that a treatment is working.

People with multiple sclerosis (MS) who have severe tremor (shakiness) affecting movement may be helped by surgery. People with severe spasticity (muscle stiffness) may be helped by insertion of a spinal pump to deliver medications when oral medications fail.

Surgery Choices

Surgery options include:

• Deep brain stimulation for tremor. Severe and disabling tremor that occurs with the slightest movement of the limbs may be helped by an implanted device that stimulates an area of the brain. A neurological surgeon performs the surgery to implant the device.
• Implantation of a drug catheter or pump, for spasticity. People who have severe pain or spasticity may benefit from having a catheter or pump placed in the lower spinal area to deliver a constant flow of medication, such as baclofen (Lioresal).

What To Think About

Deep brain stimulation usually is a last resort after all other options have been tried without success to treat MS symptoms. Only people with severe tremor are candidates.

The unpredictability and variety of symptoms caused by multiple sclerosis (MS) make it a disease that people have tried to treat in many different ways.

Experimental medical treatments

Experimental treatments for MS involve reducing the activity of the immune system with immunosuppressants or through methods such as total lymphoid irradiation, in which the entire lymph node system is exposed to radiation. While these have been used successfully in the treatment of certain other medical conditions, they have failed to produce significant benefits when tested in controlled clinical trials. They remain experimental treatments for MS, although they may be considered for people who do not respond to any other therapy.

Stem cell transplant—which uses immature cells from the bone marrow—has been tried in small studies, but there is no evidence that the risks of the procedure outweigh the possible benefits.¹⁰ It is not currently recommended for treating MS.

Complementary therapies

Other types of treatment for MS are provided by therapists or others who do not operate within mainstream medical practice. Their alternative medical approaches attract many people with MS, particularly those who have not had much success with conventional treatments. One survey found that 1 out of 3 people with MS had visited a provider of unconventional therapy, such as massage, chiropractic, or nutrition, in the previous 6 months, usually in addition to more standard therapy.¹¹

None of these complementary therapies have been shown through clinical research to be effective in treating MS and are not recommended by most doctors. However, sometimes people with MS find that even though complementary therapies do not slow the progression of the disease, the therapies help them feel better. Talk to your doctor if you are interested in trying any of the complementary therapies.

Other Treatment Choices

Many complementary therapies have been proposed as treatments for MS. None of these treatments have been shown to modify the course of the disease. Some of those most commonly used are:

• Diets and vitamin, mineral, herbal, or dietary supplements.
• Acupuncture.
• Massage therapy (often used by physical therapists).
• Biofeedback.
• Yoga.

Although clinical research has not shown any of these complementary therapies to be effective, a person with MS may benefit from safe nontraditional therapies that complement conventional medical treatment. Some complementary therapies may help relieve stress, muscle tension, and improve your overall well-being and quality of life.

Clinical research also has been unable to show that treatments such as bee venom therapy, Procarin (a caffeine and histamine combination), removal of mercury fillings (dental amalgams), and hyperbaric oxygen therapy have any benefits for people with MS. Some of these therapies may be harmful as well as expensive and are not recommended by most experts.

What To Think About

There is no cure for MS. So far, the only treatments proven to affect the course of the disease are interferon beta (Avonex, Rebif, and Betaseron), glatiramer acetate (Copaxone), and mitoxantrone (Novantrone). Other types of treatment should not replace these medications if you are a candidate for treatment with them.

No complementary therapies have been proven effective in the treatment of MS, but some people have reported that complementary therapies have worked for them. This may be in part due to the placebo effect, which is common in people who are being treated for MS. This also may be due to the fact that some complementary therapies, while not treating the disease itself, may affect a person's overall sense of well-being and help the person feel better and healthier. And, in some cases, symptoms may improve on their own.

If you have MS and are thinking about trying a complementary treatment, get the facts first. Consider these questions with your doctor:

• Is it safe? Talk with your doctor about the safety and potential side effects of the treatment. This is especially important if you are on drug therapy for MS, because some complementary treatments in combination with drug therapy can be quite dangerous. A treatment that could be harmful to you and may or may not improve your symptoms is not worth the risk.
• Does it work? Because MS symptoms can come and go, you may find it difficult to judge whether a particular treatment is really working. Keep in mind that if you get better after using a certain treatment, the treatment is not always the reason for the improvement. MS may often improve on its own (spontaneous remission).
• How much does it cost? An expensive, unproven treatment that may or may not help you may not be worth its cost. Beware of therapy providers or products that require a large financial investment at the beginning of a series of treatments.
• Will it improve my general health? Even if they are not effective in treating MS, some complementary practices (such as massage, yoga, or acupuncture) may be safe and may lead to healthy habits that improve your overall well-being. These might be worth trying.

With a hard-to-treat disease like MS, it can be tempting to jump at the promise of an effective treatment. Be cautious about trying unproven treatments.

Citations

1. Victor M, Ropper AH (2001). Multiple sclerosis and allied demyelinative diseases. In Adams and Victor's Principles of Neurology, 7th ed., pp. 954–982. New York: McGraw-Hill.

2. Bennett KA (2005). Pregnancy and multiple sclerosis. Clinical Obstetrics and Gynecology, 48(1): 38–47.

3. Giesser B (2003). Reproductive Issues in Persons With Multiple Sclerosis. Clinical Bulletin: Information for Health Professionals. New York: National Multiple Sclerosis Society.

4. Frohman EM (2003). Multiple sclerosis. Medical Clinics of North America, 87(4): 867–897.

5. McDonald WI, et al. (2001). Recommended diagnostic criteria for multiple sclerosis: Guidelines from the International Panel on the Diagnosis of Multiple Sclerosis. Annals of Neurology, 50(1): 121–127.

6. Polman CH, et al. (2005). Diagnostic criteria for multiple sclerosis: 2005 revisions to the McDonald Criteria. Annals of Neurology, 58(6): 840–846.

7. Sadiq SA (2005). Multiple sclerosis. In LP Rowland, ed., Merritt's Neurology, 11th ed., pp. 941–963. Philadelphia: Lippincott Williams and Wilkins.

8. Tintoré M (2003). New diagnostic criteria for multiple sclerosis: Application in first demyelinating episode. Neurology, 60(1): 27–30.

9. Bogglid M, Ford H (2004). Multiple sclerosis. Clinical Evidence (12): 1841–1858.

10. Fassas A, et al., (2002). Hematopoietic stem cell transplantation for multiple sclerosis: A retrospective study. Journal of Neurology, 249(8): 1088–1097.

11. Schwartz CE, et al. (1999). Utilization of unconventional treatments by persons with MS: Is it alternative or complementary? Neurology, 52(3): 626–629.

Author:	Shannon Erstad, MBA/MPH	Last Updated March 23, 2006
Medical Review:	Kathleen Romito, MD - Family Medicine Barrie J. Hurwitz, MD - Neurology
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