Signs and Symptoms of Multiple Sclerosis Flare
Multiple sclerosis flares typically present with new or worsening neurological symptoms that develop over days to weeks, including visual disturbances, sensory changes, motor weakness, and cognitive difficulties depending on which areas of the central nervous system are affected.
Common Presentations of MS Flares
Visual Symptoms
- Optic neuritis (occurs in 20-31% of initial presentations) 1
- Visual impairment or loss
- Scotoma (blind spots)
- Red-green color desaturation
- Pain with eye movement
- Blurred vision 2
Sensory Symptoms
- Paresthesia (tingling, pins and needles sensation) 2
- Numbness in limbs 1
- Electric-shock sensations (particularly with neck flexion, known as Lhermitte's sign) 1
- Sensory disturbances 3
Motor Symptoms
- Weakness in limbs 1
- Paraparesis (partial paralysis of lower limbs) 2
- Hemiparesis (weakness affecting one side of the body) 2
- Monoparesis (weakness in one limb) 2
- Tremor or lack of coordination 1
- Gait problems
- Spasticity
Brainstem and Cerebellar Symptoms
- Diplopia (double vision) 2
- Internuclear ophthalmoplegia (failure of ipsilateral eye adduction with contralateral eye abduction nystagmus) 4
- Vertigo
- Ataxia (lack of coordination)
- Dysarthria (speech difficulties) 2
Cognitive and Psychological Symptoms
- Difficulty concentrating
- Memory problems
- Fogginess
- Behavioral and neuropsychological alterations 2
- Emotional changes (irritability, sadness, nervousness)
Other Common Symptoms
- Fatigue (often severe and debilitating) 1
- Bladder and bowel dysfunction 1
- Sexual dysfunction
- Heat sensitivity (symptoms worsen with increased body temperature)
- Aphasia (language difficulties) 2
Characteristics of MS Flares
Temporal Pattern
- Symptoms typically develop over days to weeks
- Last at least 24 hours 5
- May persist for weeks to months
- Often improve with time or treatment
Spatial Pattern
- Symptoms reflect the location of lesions in the central nervous system
- May affect multiple neurological systems simultaneously
- Commonly involve optic nerves, spinal cord, brainstem, and cerebellum 4
Diagnostic Features on Imaging
MRI Findings During Flares
- New or enlarging T2-hyperintense lesions 1
- Gadolinium-enhancing lesions indicating active inflammation 1
- Characteristic locations:
- Periventricular (around ventricles)
- Juxtacortical (touching or within the cortex)
- Infratentorial (brainstem, cerebellar)
- Spinal cord 2
Red Flags (Atypical for MS)
Symptoms that should prompt consideration of alternative diagnoses:
- Sudden onset of bilateral hearing loss
- Antecedent fluctuating hearing loss
- Severe bilateral vestibular loss
- Concurrent eye pain, redness, lacrimation, and photophobia
- Recent head trauma or barotrauma
- Intractable nausea, vomiting, or hiccups (may suggest area postrema syndrome in NMOSD) 2
Clinical Pearls
- MS symptoms vary widely depending on which nerve fibers are affected 1
- Symptoms often worsen with heat exposure or fever (Uhthoff's phenomenon)
- Relapse severity can range from mild to severely disabling
- Symptoms may completely resolve between flares in relapsing-remitting MS
- Persistent symptoms may indicate progression rather than acute flare
- Early recognition and treatment of flares can help prevent long-term disability
Understanding these signs and symptoms is crucial for early diagnosis and treatment of MS flares, which can help prevent long-term disability and improve quality of life for patients with multiple sclerosis.