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) — periods when symptoms get worse or new symptoms appear — and remissions — times when 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?

In MS, inflammation in the central nervous system (brain and spinal cord) causes damage to the myelin sheath, which protects the nerve fibers, and the underlying nerve fibers. According to a review article for general neurologists on updates in the diagnosis and management of MS, the foundation of treatment is preventing flares to avoid long-term decline.

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 pseudorelapse or pseudoexacerbation. Fatigue, fever, heat, humidity, infections (such as urinary tract infections), and overexertion can cause pseudoexacerbations. So can other illnesses, depression, and stress, according to the Multiple Sclerosis Association of America. While the symptoms of a pseudoexacerbation are real, there is no new damage being done to the central nervous system.

In contrast, true flares can last anywhere from a few days to a few weeks or months, according to the NMSS.

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

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

Many people begin to recognize signals 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 RRMS 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 her, numbness and increased 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:

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

When you know how MS usually affects you, monitoring how you feel 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 of noticing what’s happening in your body without 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 stress out 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. If you have any doubt or uncertainty about whether a flare is happening, you should reach out to your MS neurologist.

How to Treat an MS Relapse

Not all flares require treatment. Mild sensory changes or episodes of fatigue that don’t significantly affect your daily life can usually be left to resolve on their own, according to 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 a 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:

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

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 of relapses, per the NMSS. It can take a few tries to find the drug that works best for you.

In addition to taking 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.”

Here are a few self-care tips for managing some common MS symptoms.

Have a plan to head off fatigue. MS fatigue is not like normal fatigue. It can be so severe that it’s disabling. “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 work-arounds for brain fog. Slowed thinking, confusion, and difficulty concentrating are frequent but underrecognized 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.”

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

Everyday Health follows strict sourcing guidelines to ensure the accuracy of its content, outlined in our editorial policy. We use only trustworthy sources, including peer-reviewed studies, board-certified medical experts, patients with lived experience, and information from top institutions.

Sources

Relapsing-Remitting Multiple Sclerosis (RRMS). National Multiple Sclerosis Society.
Secondary Progressive Multiple Sclerosis (SPMS). National Multiple Sclerosis Society.
Baskaran AB et al. Current Updates on the Diagnosis and Management of Multiple Sclerosis for the General Neurologist. Journal of Clinical Neurology. May 2023.
Managing Relapses in Multiple Sclerosis. National Multiple Sclerosis Society.
Relapse Management. National Multiple Sclerosis Society.
What Is a ‘Pseudoexacerbation’? Multiple Sclerosis Association of America.
Multiple Sclerosis Symptoms. National Multiple Sclerosis Society.
Courtney SW. Acthar Gel. Multiple Sclerosis Association of America.
Rehabilitation. National Multiple Sclerosis Society.
Disease-Modifying Therapies for MS [PDF]. National Multiple Sclerosis Society. August 2023.
Fatigue. Multiple Sclerosis Association of America. December 2023.
Tacchino A et al. Cognitive Rehabilitation in Multiple Sclerosis: Three Digital Ingredients to Address Current and Future Priorities. Frontiers in Human Neuroscience. February 23, 2023.

Show Less

Meet Our Experts

See Our Editorial PolicyMeet Our Health Expert Network

Jason Paul Chua, MD, PhD

Medical Reviewer

Jason Chua, MD, PhD, is an assistant professor in the Department of Neurology and Division of Movement Disorders at Johns Hopkins?School of Medicine. He received his training at the University of Michigan, where he obtained medical and graduate degrees, then completed a residency in neurology and a combined clinical/research fellowship in movement disorders and neurodegeneration.

Dr. Chua’s primary research interests are in neurodegenerative disease, with a special focus on the cellular housekeeping pathway of autophagy and its impact on disease development in diseases such as Parkinson disease. His work has been supported by multiple research training and career development grants from the National Institute of Neurological Disorders and Stroke and the American Academy of Neurology. He is the primary or coauthor of 14 peer-reviewed scientific publications and two peer-reviewed online learning modules from the American Academy of Neurology. He is also a contributing author to The Little Black Book of Neurology by Osama Zaldat, MD and Alan Lerner, MD, and has peer reviewed for the scientific journals Autophagy, eLife, and Neurobiology of Disease.

See full bio

Chris Iliades, MD

Author

Chris Iliades, MD, is a full-time freelance writer based in Boothbay Harbor, Maine. His work appears regularly on many health and medicine websites including Clinical Advisor, Healthgrades, Bottom Line Health, HeathDay, and University Health News. Iliades also writes a regular blog for The Pulse, a website for fetal health and pregnancy.

Iliades is board-certified in Ear, Nose and Throat and Head and Neck Surgery. He practiced clinical medicine for 15 years and has also been a medical director for diagnostic research and a principal investigator for clinical research before he turned to full-time medical writing.