What causes MS flares?

Worried About MS? 4 Triggers That Can Cause Flares

For Americans living with multiple sclerosis (MS), the majority are initially diagnosed with relapsing-remitting MS, or when the symptoms ebb and flow. Although the flares of numbness, pain, dizziness, and imbalance can be unpredictable, there are certain triggers that cause the flare ups for many people.

“When a new neurological symptom develops in multiple sclerosis, one that isn’t related to an infection, and lasts for more than 24 hours, it is considered to be an MS relapse,” explains Devon Conway, MD, a neurologist at the Cleveland Clinic. While a relapse that causes serious symptoms usually needs to be treated, old symptoms that reappear are not as serious and often go away without needing treatment.

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4 Common Triggers of an MS Flare

MS symptoms are different for everyone and may change from one flare to another, but there are triggers everyone with multiple sclerosis should be aware of. “Although a flare or relapse can occur without any warning, certain triggers are common,” says Matthew McCoyd, MD, a neurologist, assistant professor, and associate neurology residency program director with the Loyola University Health System in Illinois.

Here, the most common triggers of an MS flare-up:

  • Stress. Emotional stress is part of having a chronic disease like MS and can lead to the common MS symptom of depression. Stress can also lead to other MS symptoms, such as fatigue and confusion. An important aspect of MS treatment is creating a support network that may include loved ones who can physically help out, as well as a support group that can provide emotional strength. You may also want to consider a stress-relieving activity like meditation.
  • Fatigue. While sleep is important for everyone, it’s essential for those with MS. “Most people with MS have a lower reserve of energy,” Conway says. “Little things like a lack of sleep can trigger MS symptoms. Good health habits like eating well, sleeping well, and getting some exercise every day help fight MS fatigue.”
  • Infection. Infections are the cause of about one-third of all flares of MS symptoms. “Urinary tract infections are common causes because some people with MS have reduced bladder function,” says Dr. Conway. But any infection that weakens the immune system, like a cold or the flu, can cause a flare. So wash your hands frequently, get a yearly flu shot, and avoid being around people who are sick.
  • Heat. An infection that leads to a fever is especially troublesome to those with MS since increased body heat is a common trigger. “In the old days, a hot-bath test was one of the ways doctors diagnosed MS,” notes Dr. McCoyd. MS symptoms, especially tingling, are usually worse in the summer because of the heat. Getting into air conditioning or taking a cool shower usually helps reduce heat symptoms. Some people also get relief from wearing a vest filled with cool water.

When to Treat MS Flares

Not all MS symptoms need to be treated. Tingling, fatigue, and mental fog generally go away on their own once the trigger is removed. However more severe MS symptoms that affect your ability to function normally, such as severe weakness, poor balance, or loss of vision, do need to be treated, usually with a short course of steroids for severe MS symptoms.

“Flares and triggers are different for everyone with MS,” Conway notes. “Each person should learn to identify their own individual triggers.” If you or a loved one has multiple sclerosis, learning as much as you can about MS, getting help and support, making healthy lifestyle choices, and avoiding common triggers will go a long way toward living well with this chronic disease. Always let your doctor know about any new MS symptoms or any MS symptoms that last for more than a day and are interfering with your ability to function normally.

How to Prevent Flare-Ups

Certain things can start a relapse. Everyone’s triggers are different. Learn what brings on your symptoms so you can avoid them.

To prevent flare-ups:

Take your medicines. The drugs your doctor prescribes slow your MS from getting worse and help prevent relapses. If you have side effects, don’t just stop taking them. Ask your doctor about other options.

Keep up your health. A bout of cold or flu can set off your MS symptoms. A bladder infection can trigger a flare-up, too. Wash your hands with warm water and soap during the day, get your yearly flu shot, and avoid people who look sick. Stay hydrated. Ask your doctor for other ways to avoid bladder infections.

If you smoke, quit. It’s bad for you in so many ways, and it can make your MS symptoms worse. Talk to you doctor about ways to break the habit.

Relax. In some people, stress can bring on a relapse. Chill out with meditation, yoga, or anything else that’s good for you and helps you unwind.

Rest. You won’t feel well when you’re worn out. Sleep problems are common in people with MS. Symptoms like pain and muscle spasms can keep you up at night. Some of the medicines that treat MS interrupt sleep, too. Work with your doctor to get your symptoms under control so you can sleep. Adjust your medicines if they keep you awake.

If you have multiple sclerosis, you can do things to help limit unpredictable flare-ups of pain, dizziness, numbness and imbalance. In particular, people with relapsing-remitting MS, can take steps to avoid certain behaviors and situations that trigger MS flare-ups or relapses.

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Neurologist Alexander Rae-Grant, MD, identifies eight triggers that may lead to relapses or flare-ups.

Avoid these 8 common triggers

1. Stress: Major stress may worsen MS symptoms. “You can deal with stress through meditation, yoga, psychological counseling and by making decisions that reduce stress,” Dr. Rae-Grant says.

2. Smoking: Smoking is a major risk factor for MS progression, so stopping smoking is critical.

3. Heat: Some patients are especially susceptible to heat, and symptoms may worsen whether you encounter heat outside in the sun or in hot tubs or saunas. On the other hand, some people have no problems with heat.

4. Certain medicines that may worsen MS: “These are primarily very specific medicines used for rheumatoid arthritis or Crohn’s disease,” Dr. Rae-Grant explains. “But it’s wise to check the medicine list and make sure medicines you are using are not a negative for MS.”

5. Too many medicines: Some people with MS end up on a raft of medicines which may interact with each other and cause side effects. Dr. Rae-Grant recommends working with your doctor to see which medicines are absolutely necessary and which ones you can reduce or stop taking.

6. Stopping your MS medicines: Some people go off of their MS medicines because they think they aren’t working or worry about side effects. According to Dr. Rae-Grant, these medicines help prevent relapses and new lesions, so it’s what you “don’t get” that the medicines do for you. “It’s like treating high blood pressure: You don’t feel any better on these medicines, but they may prevent a stroke or heart attack,” he says.

7. Fatigue: Patients with MS typically have a lower reserve of energy, so something like a lack of sleep can trigger MS symptoms. “Patients with MS have to follow similar good health rules just like everyone else,” Dr. Rae-Grant says. “You have to eat a nutritious diet, get some exercise every day and get plenty of sleep every night to counter that MS fatigue.”

8. Infection: Roughly one-third of all flare-ups of MS symptoms are the result of infections. Reduced bladder function in people with MS, for example, can cause urinary tract infections. But even more minor infections such as a cold or the flu can weaken your immune system and set off a flare-up.

Dr. Rae-Grant offers common-sense advice to help you limit illness and infections:

  • Get your yearly flu shot.
  • Avoid being around people who are ill.
  • Wash your hands regularly.

When do MS flare-ups require treatment?

Minor symptoms such as fatigue, tingling or slight confusion usually disappear on their own, once you remove the trigger.

More severe MS symptoms, however, such as serious weakness or loss of vision that prevent you from functioning normally, will need treatment. A short course of steroids can usually treat more severe MS symptoms.

“Avoiding the common triggers and maintaining a healthy lifestyle will help you live more comfortably with this chronic disease,” Dr. Rae-Grant says.

My Doctor Dismissed My MS Symptoms as ‘Stress’—Even Though My Body Was Going Numb

She (finally) sent me to a neurologist, who had me undergo an MRI. The MRI was on a Saturday, and on Sunday morning, I woke up with the worst symptoms I had ever had. I was seeing double, I couldn’t walk straight, and I was slurring my words. I felt like I was drunk.

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I called the neurologist’s office as soon as they opened on Monday morning, but no one answered. I was getting desperate. My husband packed our two kids into the car and drove me to the neurology clinic. He stayed in the car with the kids, and I wobbled into the office. Through broken sentences, I told the staff I needed to speak to the doctor right away.

That was when I got my true diagnosis. The MRI results had come in, showing that I had the neurological disorder multiple sclerosis, or MS.

I was terrified. I knew my life was about to change, but I had no idea how. I didn’t know what to expect. But at the same time, I was relieved. I finally had an answer.

Diagnosed with a lifelong disorder

It turned out my drunk symptoms were actually an MS relapse, or flare-up. MS is a disease of the central nervous system in which the immune system attacks the protective sheath, or myelin, that covers nerve fibers. This causes communication problems between the brain and the rest of the body. MS flare-ups happen when inflammation in the nervous system causes new damage to the myelin.

Doctors treated me with IV steroids, which helped bring down the inflammation that caused the symptoms. Thankfully, my mom came to stay with us after my diagnosis and helped me recover from the flare-up, which lasted about a month. During that time, my mom and the rest of my family had to take shifts driving me to the hospital to get my steroids, helping me with the kids, and basically everything else.

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My life was on hold. Just before my diagnosis, I had a job interview for a position as a correctional officer. The next step was a written test, but then the flare-up happened. I could barely see, let alone craft thoughtful responses to questions. I had to cancel it.

Even when I was technically well enough for my mom to leave, I was afraid to let her go. I was scared to be left alone with my kids. What if something happened, another flare-up, and I couldn’t take care of them? What if I couldn’t call for help?

MS affects everyone differently, and each person’s symptoms can change or fluctuate over time. For some people, MS may take their ability to walk, while others may experience long periods of remission without any new symptoms.

In the months after my diagnosis, I had to learn what MS meant for me, which wasn’t easy. Not having a clear course of action made me depressed. I thought my life was over, and I pushed everyone away. But then I had a reality check. I loved my kids, I loved my family, and I had to keep trying for them. I couldn’t give up.

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I was diagnosed in August 2010, and though my doctor had me taking 15 to 20 prescriptions simultaneously, I had another relapse three months later. This relapse was worse than the first. I was paralyzed on the entire right side of my body, leaving me unable to do much of anything. I went through about three months of treatment, including taking steroids and doing both physical and speech therapy, before my body was back to normal.

What other women need to know

That was fortunately my last relapse, and since late 2017, many of my symptoms have actually been subsiding. With time, I’ve been able to get a better understanding of how MS affects me. I’ve learned what triggers my flare-ups, how to prevent them, and what to do if I feel one coming on. But getting to that place took a lot of experimentation, and I learned the hard way that what works for someone else with MS won’t necessarily work for me.

I tell other women who are dealing with mysterious symptoms and feeling dismissed by doctors to arm themselves with knowledge. Do your research and ask your doctor informed questions. Get a second opinion, and if you’re still not satisfied, get a third. When I was first diagnosed, my doctor handed me a pamphlet—one wimpy pamphlet that was supposed to help me understand a condition that would affect me for the rest of my life.

It wasn’t until I took matters into my own hands—did research, found a doctor I trusted, spoke to other people with MS, and joined initiatives like the MS MindShift—that I began to understand my MS. Being my own best advocate has showed me that my MS doesn’t control of my life, I do.

If you have a story to share about being misdiagnosed, email us at [email protected] and join our Misdiagnosed Facebook community to talk to women who share the same struggle.

After the first round of symptoms, multiple sclerosis can stay mild without causing major problems for decades, a 30-year British study indicates.

Karen K. Chung of the University College London Institute of Neurology discussed the findings at the ECTRIMS-ACTRIMS meeting in Paris, which started Oct. 25 and runs until 28. His presentation was titled “Does ‘benign’ multiple sclerosis exist? A 30-year follow-up study of people presenting with clinically isolated syndrome.”

MS affects different people in different ways. Many patients develop nervous system impairments over time, while others remain unaffected.

Scientists refer to cases with no nervous system impairment as benign MS. But its exact definition and characteristics are still a matter of debate. And some researchers contend that benign MS does not exist.

British researchers wanted to know if people with MS can have a benign form of the disease 30 years after the first symptoms appear.

The team’s intent was to follow 132 patients with clinically isolated syndrome, or CIS — a precursor to MS — for 30 years. Some died or dropped out before the study was completed.

Researchers gave the patients magnetic resonance imaging (MRI) scans and disability assessments every five years. The disability yardstick they used was the Expanded Disability Status Scale, or EDSS.

About halfway through the study, the team added an MS functional composite test to the measurements. It assessed leg and arm function, and cognition.

In the very last evaluation, researchers also assessed cognition with a test known as the Brief International Cognitive Assessment for MS.

In addition, the team included patients’ employment history in their analysis.

From the initial pool of 132 participants, 29 had died by the time the study ended 30 years later – 16 of an MS-related cause. Twelve participants dropped out of the study, leaving 91 for the analysis.

Thirty of the 91, or 33 percent, failed to develop MS. Thirty-five, or 44 percent, had relapsing-remitting multiple sclerosis, or RMSS. And 26, or 33 percent, had the more severe secondary progressive multiple sclerosis, or SPMS.

Researchers excluded those with CIS — that is, those who had failed to develop MS — from additional analysis.

They discovered that only 11 of the 61 who had developed MS had received a disease-modifying therapy at some point or other. Eighty-eight percent of the 35 with RRMS had low disability scores, and all were either still working or had retired at a normal retirement age.

Cognition tests showed only mild impairment in three patients.

Researchers said the study suggests that “it is not uncommon for people with relapsing MS “to have only mild or no physical or cognitive dysfunction approximately three decades after clinical onset.”

MS may have a bimodal progression, the team said. Either patients continue to have a mild and stable disease, such as the majority of RRMS patients in the study, or their disease progresses to SPMS.

Nonetheless, based on the results, Chung concluded that “very stable ‘benign’ MS does exist.”

  • Author Details

Patricia holds her Ph.D. in Cell Biology from University Nova de Lisboa, and has served as an author on several research projects and fellowships, as well as major grant applications for European Agencies. She also served as a PhD student research assistant in the Laboratory of Doctor David A. Fidock, Department of Microbiology & Immunology, Columbia University, New York. × Patricia holds her Ph.D. in Cell Biology from University Nova de Lisboa, and has served as an author on several research projects and fellowships, as well as major grant applications for European Agencies. She also served as a PhD student research assistant in the Laboratory of Doctor David A. Fidock, Department of Microbiology & Immunology, Columbia University, New York. Latest Posts

MS symptoms

In some cases where the drug treatments may not be effective, Botox may be considered. Botox is injected directly into the affected muscle to help reduce the tightness caused by spasticity.

Sativex is a cannabis based spray that may help reduce spasticity. It is not generally available on the NHS. For more detailed information, see our Choices booklet, Cannabis and MS.

Spasms are different to spasticity in that, although they involve similar muscle contractions they can come on very suddenly, and relax just as suddenly. Most spasms occur in the legs and arms, and less commonly the throat. Spasms can be painful and lead to interrupted sleep. The same drug treatments for spasticity are offered to help reduce spasm.

An MS nurse with a holistic perspective has written about other suggested ways in which spasms can be managed. They are exercise, magnesium (either by tablet/spray/powder, or by rubbing directly into the skin), CBD oil and TENS machine (9).

Many people with MS use other complementary therapies to help manage spasm too. A combination approach to treating spasms is often a more preferred option.

‘Do regular exercise (even when you don’t feel like it) it can be really helpful for many symptoms like stiffness and fatigue.’


Many people with MS may experience tremor in some way. There are different types of tremor; for some it may be very mild and only noticeable by the individual. For others it may be difficult to manage and incredibly disabling.

Intention tremor is the most commonly experienced type. This is involuntary and a movement that is uncontrolled. Intention tremor in the upper limbs often worsens when reaching for an object. This can be exacerbated by stress and also fatigue.

For mild tremor, adjustments in posture such as holding an arm closer to your body when moving a cup to your mouth, can help with the stability of the movement.

Your MS nurse or GP can refer you to an occupational therapist who can offer practical advice in managing tremor – perhaps suggesting aids or appliances which can help, such as cups with easy-grip handles. A physiotherapist can also set up an exercise programme to increase strength in muscles which are weaker and may be contributing to the tremor’s severity. There are some drug therapies but these often only provide minor benefit. Sometimes the beta blocker, propranolol can have some effect, whilst in other cases, Botox has been shown to reduce head tremors.

Visual symptoms

There are several problems that can affect the vision of people with MS. The most common symptom is optic neuritis – inflammation of the optic nerve, which is also one of the more common first symptoms that can lead to a diagnosis of MS. Optic neuritis is sometimes treated with steroids to help reduce the inflammation.

Other problems can include

  • Diplopia (double vision) – Often an early symptom of MS but can also occur as part of a relapse of MS where steroids may help
  • Nystagmus – rhythmical oscillations of the eye ball which sometimes goes unnoticed by the person, but is obvious to others. A difficult symptom to treat but occasionally the drugs gabapentin and memantine may be offered

What is a relapse?

Sometimes a temporary onset, or worsening of symptoms is actually a relapse. It can often be difficult to determine if you are having a relapse. It is important to let your GP and MS nurse know if you think you are experiencing a change in symptoms so they can determine if it is a clinical relapse and therefore if treatment is required.

According to the NICE guidelines (5) a relapse can be diagnosed by a GP or neurologist if, ‘The person with MS has developed new symptoms or has a worsening of existing symptoms, and these symptoms have lasted for more than 24 hours in the absence of infection or any other cause after a stable period of a least one month.’

Choices booklets and useful resources

MS symptoms (PDF Choices booklet)

MS symptoms (Word Choices booklet)

Bladder and bowel (Web page version)

Bladder and bowel (PDF Choices booklet)

Bladder and bowel (Word Choices booklet)

Diagnosis (Web page version)

Diagnosis (PDF Choices booklet)

Diagnosis (Word Choices booklet)

Fatigue (Web page version)

Fatigue (PDFChoices booklet)

Fatigue (Word Choices booklet)

Pain (Web page version)

Pain (PDF Choices booklet)

Pain (Word Choices booklet)

Speech and swallowing (Web page version)

Speech and swallowing (PDF Choices booklet)

Speech and swallowing (Word Choices booklet)

Visual symptoms (Web page version)

Visual symptoms (PDF Choices booklet)

Visual symptoms (Word Choices booklet)

Newly diagnosed booklet (PDF document)

Symptom diary (PDF document)

Symptom diary (Word document)

Am I having a relapse? form (PDF document)

Am I having a relapse? form (Word document)

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