When MS Attacks

Call it a flare-up, call it an exacerbation -- whatever you call it, you can't call it fun. Exacerbations of multiple sclerosis are the periodic, sudden worsening of symptoms that so many people with relapsing-remitting MS experience on a regular basis. You're walking along fine when you notice numbness in your right leg. Or suddenly you have double vision. If those symptoms last at least 24 hours, you're going through an exacerbation.

"Exacerbation is a more rapid evolution of new symptoms or worsening of old symptoms than just the overall progression of the disease by itself," says John Richert, MD, vice president for research and programs with the National Multiple Sclerosis Society. "It comes on over a period of hours or days, as opposed to a slow progression that occurs over months and years."

Inside an MS Flare-Up

What's going on inside the brain when someone with MS experiences a flare-up?

Generally, when you experience relapse symptoms it means that "there are new lesions forming in the brain or spinal cord that disrupt neural transmission -- literally, new disease activity," says Patricia Coyle, MD, professor of neurology at the State University of New York at Stony Brook and director of the Stony Brook Comprehensive MS Center.

But not all symptoms are tied to brain lesions. Fatigue, for example, usually doesn't signal a flare-up in the brain. Although extreme fatigue accompanied by a worsening of other neurological symptoms might be, says Coyle.

Sometimes, what feels just like an MS exacerbation really isn't one. An infection or fever can cause a temporary problem with nerve conduction in previously damaged areas of the brain, explains Coyle. So if you have the flu, you might experience symptoms that seem like a flare-up. "It's not actually a sign of a new lesion, but rather temporary disruption in areas of old damage where nerve impulses were conducting normally," she says. "If we treat the fever or the infection, then we should see a complete reversal to where the patient was before."

Managing MS Flare-Ups

But when it's a real flare-up, the good news is it can be managed. Most doctors treat multiple sclerosis exacerbations with high-dose steroids, most commonly given in a half-hour IV infusion daily for three to five days. You can also take oral steroids, but you'd have to take a lot of pills to get that same effective high dose, so most patients opt for IV.

"What can steroids do?" asks Coyle. "They can speed up the time frame of recovery from an acute relapse. Most experts don't think they affect the ultimate degree of recovery from a flare-up. That question probably requires further study. But you do recover faster with them than without them."

Of course, you don't have to take steroids. With a mild flare-up, says Richert, many doctors would advise people with multiple sclerosis to watch and wait to see if it gets better on its own. "But if you're really affected -- if you can't work, can't climb the stairs, can't drive the car, can't do the things you need to do in daily life -- that's a reason to try and get through it as quickly as possible."

The Goal: Faster Relief From MS Symptoms

How quickly is that?

"Most patients will begin to see improvement within a few short weeks," says Coyle. "Many will get significant improvement within three months or so. Part of the difficulty with relapse is you can never be sure of degree of recovery. In the early years of the disease, usually people experience milder relapses and quicker recovery. More severe relapses, involving things like muscle weakness or loss of bladder function, tend to take longer for recovery."

If you've had an extremely debilitating attack and steroids haven't helped at all, some evidence shows that symptoms may respond to a course of plasma exchange or intravenous immunoglobulin. "The data aren't the strongest, but it's an option to discuss with your neurologist, says Coyle.

In general, she says, people who treat flare-ups should see significant recovery within three months, although recovery can occur as late as one year out. One year after a flare-up, whatever symptoms you still have are likely to remain.

Taking Care of Yourself During an MS Flare-Up

Besides steroids and other medicine, how else can you manage a flare-up? Ellen Sue Stern, author of Words of Inspiration for People with MS, and a public speaker in Minnesota, experiences draining fatigue every six months or so, often accompanied by a worsening of the trigeminal neuralgia (severe facial pain) that has been the primary feature of her multiple sclerosis.

"You have to really pay attention to your body and what's going on inside of you," she advises. "Be really tuned in. If you're not, you may get taken by surprise and have made commitments or taken on extra work and things you can't do. That just puts on more stress and pressure and makes it harder. Be very clear about what your priorities are. That means saying no sometimes. And don't be afraid to ask for help."

Coyle agrees. "If this is a new relapse, then there's an acute process going on right now," she says. "That means that people should temporarily take it easy and not do things that will stress or tax them physically. Just baby yourself for a couple of days. It doesn't have to be a long-term thing but don't go out right away and try to do business as usual."

Get enough sleep, she advises, and stay hydrated.

No matter how you manage an exacerbation, it's important to remember that they don't mean that the disease-modifying medications you're taking for MS aren't working. "Even when you're on medications, you'll still have exacerbations," says Stern. "The drugs aren't a magic bullet that stops everything, but they do slow down the disease process, so stay with them."

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