How can winter exacerbate neurological conditions and what management strategies can help?

Winter Exacerbation of Neurological Conditions

Winter temperatures below 13°C significantly worsen neurological conditions, particularly increasing stroke severity, triggering symptom flares in multiple sclerosis, and exacerbating Raynaud's phenomenon in systemic sclerosis patients. 1, 2

How Winter Exacerbates Neurological Disease

Stroke and Cerebrovascular Disease

• Cold exposure (<13°C) increases stroke severity through multiple mechanisms: prolonged prothrombin time (PT), shortened thromboplastin time (TT), and higher rates of large artery atherosclerotic stroke 1
• Patients admitted during cold periods show significantly higher NIHSS scores (worse neurological deficits) compared to warmer periods 1
• Hypertension rates increase during cold exposure, contributing to elevated stroke risk 1
• The coagulation system becomes prothrombotic in cold weather, with impaired platelet function when body temperature drops 3

Multiple Sclerosis (MS)

• Temperature variations (not just heat) trigger MS exacerbations, with the standard deviation of daily temperature being the strongest predictor of clinic visits 4
• MS clinic visits increase 9% during spring, summer, and fall (March-October) compared to winter, suggesting temperature fluctuations rather than absolute cold are problematic 4
• 60-80% of MS patients experience symptom worsening with temperature changes, though this is more commonly studied with heat exposure 4
• Regional variations exist, with strongest associations in Upper Midwest, Lower Midwest, Desert Southwest, and Northeast climate zones 4

Systemic Sclerosis and Raynaud's Phenomenon

• Cold exposure is a well-documented trigger for Raynaud's phenomenon, with patients reporting more frequent and longer exacerbations during winter 2
• Cold-triggered symptoms include digital ischemia, cold urticaria (hives), and vasospastic episodes 2

Evidence-Based Management Strategies

Non-Pharmacological Interventions (First-Line)

For Cold-Induced Symptoms:

• Use gloves and heating devices for hands to maintain peripheral warmth 2
• Avoid direct contact with cold surfaces and sudden temperature changes 2
• Thoroughly dry skin after moisture exposure to prevent evaporative cooling 2
• Maintain stable indoor temperatures to minimize temperature fluctuations for MS patients 4

For Stroke Prevention in Cold Weather:

• Monitor blood pressure more frequently during cold snaps, as hypertension rates increase 1
• Ensure adequate hydration to counteract cold-induced hemoconcentration 1
• Limit outdoor exposure during extreme cold (<13°C for 5+ consecutive days) 1

Pharmacological Management

For Systemic Sclerosis with Cold-Induced Symptoms:

• Second-generation H1-antihistamines are first-line for cold urticaria, with dosing increased up to four times standard dose for refractory cases 2
• Omalizumab should be considered for antihistamine-resistant cold urticaria 2
• Mycophenolate mofetil (MMF) is first-line for SSc-ILD, with methotrexate if musculoskeletal involvement predominates 2
• Tocilizumab, rituximab, and nintedanib are second-line options for progressive fibrosing ILD 2

For Temperature-Related Neurological Symptoms:

• Acetaminophen and magnesium can be used for temperature control in acute neurological conditions 3
• Avoid aggressive hypothermia protocols (<36°C) outside of specific cardiac arrest scenarios, as evidence for benefit in stroke is insufficient 3

Monitoring and Surveillance

Critical Monitoring Parameters:

• Regular pulmonary function tests in early diffuse cutaneous SSc patients 2
• Blood pressure monitoring to detect early scleroderma renal crisis 2
• Coagulation indices (PT, TT) during cold weather in high-risk stroke patients 1
• Daily temperature variations for MS patients in high-risk climate zones 4

Critical Pitfalls to Avoid

Medication-Related:

• Avoid glucocorticoids in early diffuse cutaneous SSc due to increased scleroderma renal crisis risk 2
• Do not use therapeutic hypothermia routinely for acute ischemic stroke, as clinical trials show no benefit and potential harm (hypotension, arrhythmias, pneumonia) 3

Management Errors:

• Do not dismiss winter symptom exacerbations as "just the weather"—they represent real pathophysiological changes requiring intervention 1, 4
• Avoid assuming only heat affects MS; temperature variability is equally or more important 4
• Do not overlook the 14-day window before symptom onset when assessing cold exposure impact 1

Multidisciplinary Referral Indications

When to Refer:

• Pulmonology consultation if ILD is detected in SSc patients 2
• Dermatology for refractory cold urticaria management 2
• Physical and occupational therapy to improve functional impairment in SSc despite cold-induced symptoms 2
• Neurology for MS patients with frequent temperature-triggered exacerbations requiring disease-modifying therapy adjustment 4

Regional Considerations

The impact of winter on neurological conditions varies by climate zone, with strongest associations in Upper Midwest, Lower Midwest, Desert Southwest, and Northeast regions where temperature variability is greatest 4. Clinicians in these areas should maintain heightened awareness during seasonal transitions when temperature fluctuations are most pronounced 4.