Exacerbation

It can be difficult to know when new neurologic symptoms represent a MS exacerbation or flare or when they represent a false or pseudo-exacerbation. A true exacerbation results from a new MS lesion in the brain or spinal cord. MS exacerbations or flares typically develop over hours to days rather than seconds. The new symptoms usually last for at least 24 hours. The area where the new lesion is located in the nervous system will determine the type of symptoms the lesion causes. A pseudo-exacerbation is a worsening of symptoms in the setting of an external complicating factor that is not related to an actual new lesion from your MS.

Some potential causes include: infections (viral or bacterial), elevated core body temperature (related to exercise activity or the environment), new medications, physical overuse or over-activity, and stress. Usually, we can help to determine whether a new problem represents a new exacerbation or pseudo-exacerbation. In general, new exacerbations cause symptoms you have not previously experienced. True exacerbation symptoms tend to involve more isolated parts of the body. Pseudo-exacerbation symptoms often involve many different systems and body parts. It can be difficult even for us to determine the exact nature of symptoms; however, the list below may be helpful.

Common True Exacerbation Symptoms

  • Loss or blurred vision in one eye
  • Double or jumpy vision
  • Numbness or tingling (in one limb, both legs or half the body)
  • Weakness (in one limb, both legs or half the body)
  • Balance difficulties
  • Tremors
  • Abdominal or chest tightness (“the MS hug”)
  • Electric shock-like sensation when the neck is flexed (Lhermitte’s)

More Common Pseudo-exacerbation Symptoms

  • Generalized weakness
  • Cognition or memory change
  • Fatigue
  • Bladder changes (frequency, urgency, slow flow, double voiding, hesitancy)
  • Bowel changes (constipation, diarrhea)

If any of these symptoms occur, you should notify us. Evaluation of both exacerbations and pseudo-exacerbations is important. While steroids may speed recovery from true exacerbations, they are not usually used to treat pseudo-exacerbations. Removing the cause of the pseudo-exacerbation will usually result in the resolution of your symptoms within a day or so.

When you suspect an exacerbation or pseudo-exacerbation is occurring, we ask that you review your recent health with attention to infections, new medications, and other recent activity or changes. Please let us know about any changes in your urinary bladder control or the clarity or odor of your urine. Also, let us know about even mild respiratory or gastrointestinal infections. We ask that you take your temperature before contacting us.

We will often ask that you have your urine checked for infection and in some cases may ask that you have a chest x-ray or visit with your family doctor to look for other issues. Blood levels may be checked if you are on a medication which may aggravate MS symptoms. If you are on an interferon beta type medication (Betaseron, Avonex, Rebif, Extavia) or natalizumab (Tysabri), we may ask that you have a blood test for antibodies that interfere with the medications effectiveness. If you are on natalizumab (Tysabri), any worsening should be immediately communicated to our nurses as it could represent the brain infection, PML.

We will want to know if you have had any recent MRI scans and, if so, when and where. We will often request an MRI scan of the appropriate region to evaluate for true exacerbations. The type of symptoms you are experiencing will determine what type of MRI scan we will order.

True exacerbations indicate that your MS is not currently under complete control. If you're not on a disease modifying therapy for your MS, your neurologist may discuss starting one with you. If you are on disease modifying medication for your MS, please honestly report if you've had difficulty taking it as prescribed for any reason (side effects, cost, other). Your neurologist will discuss whether this exacerbation and associated changes on your examination and MRI scan indicate a need to reconsider your long-term MS therapy.

Not all exacerbations require treatment with corticosteroids such as methylprednisolone (Solu-Medrol) or ACTH. These agents may speed recovery from exacerbations but do not necessarily improve the amount of recovery. Your neurologist will decide if these agents are necessary. Our MS center team will assist you in arranging your treatment if necessary. Please remind us if you have had any difficulty with these medications in the past (significant side effects) or if you have other medical conditions, such as diabetes, that may require special care. Please see our information page on Solu-Medrol elsewhere on this website for a review of potential side effects.