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Multiple Sclerosis Centers of Excellence

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Definition and Diagnosing MS Acute Attacks

James Bowen, MD Medical Director, Multiple Sclerosis Center

Swedish Neuroscience Institute, Seattle, WA

 

Definition

Differential Diagnosis for MS Acute Attacks

Treatment for Acute Attacks

Definition of Terms

 

Definition

 An attack is the same as a flair, relapse, or exacerbation.

  • Attacks involve subjective or objective neurological dysfunction.
  • The neurological dysfunction should be typical of that seen with MS. For example, pain should not automatically be assumed to be due to the MS, but intercurrent illnesses1 should also be considered.
  • Attacks must last at least 24 hours.
  • More typically, they last several days or a few weeks.
  • In general, the attack ends at the nadir of neurological dysfunction2. Continued but stable neurological dysfunction beyond the nadir represents a failure to recover rather than ongoing inflammation.

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Differential Diagnosis for MS Acute Attacks

  • Paroxysmal symptom3 lasting less than 24 hours do not represent attacks unless there is an abrupt change in frequency that recurs repeatedly over at least 24 hours.
    • Tonic spasms–bouts of muscle stiffness or dystonic posturing4, usually lasting a few minutes. Typically, the legs would go into rigid extension.
    • Painful paroxysmal symptoms–bouts of pain or paresthesia5 usually lasting a few minutes.
    • Lhemitte’s phenomenon consists of a shock-like sensation beginning in the neck and spreading down into the arms or legs. It is typically precipitated by neck flexion.
    • Trigeminal neuralgia6 may be caused by MS. However, these symptoms also resemble those seen in non-MS patients.
  • Pseudo-exacerbation7 due to increased body temperature. Patients with MS often have an increase in old symptoms, or may develop new symptoms in the presence of increased body temperature. This increase may be due to environmental factors like hot weather, hot tubs, or hot showers. Fevers are also a common cause of temperature-related pseudo-exacerbations.
  • Pseudo-exacerbation due to intercurrent illness. Any severe intercurrent illness may lead to worsening MS symptoms. Bladder and upper respiratory infections are particularly common, though non-infectious disease may also increase symptoms. Some infections may occur simultaneously with an attack, requiring that both conditions be treated.
  • Musculoskeletal pain 

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Treatment for Acute Attacks

Treatment for MS attacks is described in several articles on MS Therapies page.

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Definition of Terms

1. Intercurrent illness: A separate illness that occurs at the same time as another disease that can affect the course of the disease. For example: One could be having a MS attack and also have a bladder infection. The bladder infection would be an intercurrent illness that might affect the outcome of the attack.

2. Nadir of neurological dysfunction: Nadir refers to the lowest point. For example: From the time of a MS attack that leads to the point of one experiencing neurological dysfunction.

3. Paroxysmal symptoms: A sudden attack or recurrence of brief MS symptoms. For example: spasms, weakness, pain, double vision.

4. Dystonic posturing: Dystonia refers to a neurologic movement disorder that affects involuntary muscle movements. For example: involuntary muscle spasms, muscle extensions, slow movement, bent posture.

5. Paresthesia: Refers to abnormal skin sensations with no apparent cause. For example: feelings of burning, prickling, itching, or tingling.

6. Trigeminal neuralgia: Is a nerve disorder that affects the trigeminal nerve (tri-refers to three-part nerve) that relays sensory information to the facial area, generally on one side of the face. This condition causes episodes of intense, stabbing pain that affects areas of the face where the nerve branches out.  For example: pain might be experienced in the forehead, upper jar, lower jaw, eye, and/or cheek.

7. Pseudo-exacerbation: Refers to a temporary onset of MS symptoms brought on by an external factor. Once the external factor is removed or changed the symptoms subside. For example: a common external factor is heat either from the weather or bathing in very hot water.

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Last Updated: November 2009