Relapsing remitting MS: relapses, remission, treatment and what to expect

The NHS explains that multiple sclerosis happens when the immune system attacks the brain and nerves, and that it cannot currently be cured. It lists three main types: relapsing remitting, secondary progressive and primary progressive. In relapsing remitting MS you have flare-ups of symptoms where they get worse (relapse) and then go away or get better (remission). The NHS notes that over time this type often develops into secondary progressive MS.

The MS Trust says that when you are in remission you may have no symptoms or relatively stable symptoms that vary in intensity from day to day. For every 100 people diagnosed with MS, around 85 will be diagnosed with relapsing remitting MS. It is typically diagnosed in your 30s or 40s but can be diagnosed in children and older adults, and it is two to three times more common in women than men.

The NHS lists common symptoms of MS including extreme tiredness, problems with the eyes or vision such as blurred vision or eye pain, numbness or tingling, feeling off balance, dizzy or clumsy, muscle cramps, spasms and stiffness, needing to pee more often or not being able to control it, problems with memory or concentration and sexual problems. Everyone is affected differently.

The MS Trust says the symptoms depend on where MS has caused damage in the brain and spinal cord, and that around the time of diagnosis the most common symptoms in RRMS are problems with eyesight (such as blind spots, double vision or eye pain), altered sensations such as numbness, tingling or burning including nerve pain, fatigue and cognitive problems. Some symptoms such as fatigue and altered sensations are not always obvious to other people.

The MS Trust says that to be classed as a relapse, any new or worsening symptoms must last for at least 24 hours with no other reason for the worsening, such as an infection or a raised body temperature, and a new relapse must occur at least 30 days after the start of a previous relapse. It can take a few days before you and your MS team are sure whether you are having a relapse. NICE gives the same criteria and adds that a relapse should not routinely be diagnosed if symptoms have been present for more than 3 months, and that infection, particularly urinary and respiratory infection, should be ruled out first.

Recovery varies. The MS Trust says symptoms may improve quickly or recovery may be gradual with symptoms still improving three to six months later; some symptoms go away completely, while others may partially improve, stay the same or become permanent. Many everyday fluctuations in MS are not relapses.

The NHS says that if a GP thinks you could have MS they will refer you to a neurologist, and that there is no single test. Tests may include checks on movement, coordination, vision, balance and reflexes, blood tests, an MRI scan to see whether there is damage to the nerves in the brain or spinal cord, a lumbar puncture, and tests using small sensors on the skin to measure how quickly messages from the eyes or ears travel to the brain. The neurologist may need to monitor symptoms and test results for some time to decide which type you have.

NICE says MS should be diagnosed by a consultant neurologist or a specialist under their supervision, using a combination of history, examination, MRI and laboratory findings, following the 2024 revised McDonald criteria. NICE advises against referring people suspected of MS whose only symptoms are fatigue, depression, dizziness or vague sensory symptoms, unless there is a history or evidence of focal neurological symptoms or signs.

NICE says that relapses affecting the ability to perform usual tasks should be assessed and offered treatment as early as possible and within 14 days of onset. It recommends oral methylprednisolone 0.5 g daily for 5 days, with intravenous methylprednisolone 1 g daily for 3 to 5 days as an alternative where oral steroids have failed or not been tolerated or where admission is needed. Not all relapses need steroids, which is why non-specialists should discuss the diagnosis and the steroid decision with a professional with MS expertise.

NICE also says that the potential complications of high-dose steroids, such as temporary effects on mental health including insomnia, depression, confusion and agitation, and worsening of blood glucose control in diabetes, should be explained, and that people should not be given a supply of steroids to self-administer at home for future relapses. The MS team should be told about every relapse because relapse frequency may influence which disease-modifying therapy is chosen.

Disease-modifying therapies (DMTs) decrease the attacks made by the immune system on the brain and spinal cord, with the aim of reducing the number and severity of relapses and slowing the build-up of disability, according to the MS Trust. It says there is increasing evidence that starting a DMT soon after diagnosis minimises nerve damage and reduces disability progression, and suggests asking your neurologist or MS nurse whether one may be suitable, the risks and side effects, and when to begin.

NICE lists a number of medicines recommended as options for active relapsing remitting MS, including cladribine, ublituximab, diroximel fumarate, ponesimod, ofatumumab, peginterferon beta-1a, ocrelizumab, glatiramer acetate, interferon beta-1a, dimethyl fumarate and teriflunomide, with further options for highly active and rapidly evolving severe disease. The NHS England treatment algorithm guides prescribing. Which is right for you depends on disease activity, other health conditions, pregnancy plans and your preferences.

Symptomatic treatment matters as much. The NHS lists support such as advice about managing fatigue, physiotherapy and exercises, mobility equipment and home adaptations, cognitive behavioural therapy for anxiety, depression and fatigue, cognitive rehabilitation, and help with bladder, bowel or sexual problems. NICE says not to offer vitamin D solely for the purpose of treating MS and not to offer omega-3 or omega-6 fatty acid compounds to treat MS.

The NHS says MS is different for everyone and that no one can predict how much it will affect you. For some people the impact on daily life is small, while others have more severe symptoms. It says MS treatments are improving, so if you are diagnosed today you can expect a better quality of life than was possible before, and that most people with MS live into old age although average life expectancy is a few years less than the general population.

The NHS lists risk factors for MS including being aged 20 to 50, being a woman, having a close relative with MS, smoking, which makes people about twice as likely to develop it, and having had the Epstein-Barr virus. Stopping smoking is a sensible step if you smoke. The NHS names the MS Society, MS Trust and MS-UK as sources of support, as well as local groups and your MS nurse.

The NHS says to call 999 or go to A&E if you have sudden weakness or numbness in one arm, loss or blurring of vision, or problems with balance and coordination, because these could be signs of a stroke. If you already have a diagnosis and think you are having a relapse, contact your MS team or specialist nurse promptly, as treatment works best when started early. See a GP if you have symptoms that you think may be MS.