Intended for healthcare professionals

Clinical Review

Relapse in multiple sclerosis

BMJ 2015; 350 doi: (Published 14 April 2015) Cite this as: BMJ 2015;350:h1765
  1. Ian Galea, associate professor and consultant neurologist1,
  2. Nicki Ward-Abel, lecturer practitioner2,
  3. Christoph Heesen, professor of neurology3
  1. 1Clinical Neurosciences, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton General Hospital, Southampton SO16 6YD, UK
  2. 2Birmingham City University, Edgbaston, Birmingham, UK
  3. 3Institute for Neuroimmunology and MS, and Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
  1. Correspondence to: I Galea I.Galea{at}

The bottom line

  • Relapse of multiple sclerosis is a patient reported, or objectively observed, event typical of an acute inflammatory demyelinating event in the central nervous system, current or historical, with a duration of at least 24 hours

  • The differential diagnosis of a relapse includes alternative neurological diagnoses, pseudo-relapses, short lived paroxysmal symptoms, day to day fluctuations, and functional symptoms

  • Clinically significant or severe relapses may benefit from treatment with corticosteroid for five days

  • Documentation and timely communication of the relapse to the patient’s multiple sclerosis specialist service, such as through the multiple sclerosis specialist nurse, is important, to enable timely decisions on immunotherapy initiation or escalation

  • Non-adherence with immunotherapy is under-recognised by both patients and doctors

Multiple sclerosis is an autoimmune inflammatory disorder of the central nervous system. The global prevalence of the condition varies widely, with the most recent meta-analysis finding an increase in 3 cases per 100 000 per degree of latitude.1 The disease is more common in females, with a female to male incident ratio of 2.4.2

This review discusses the recognition and management of relapses in multiple sclerosis, and focuses on facts that are applicable to the generalist, not specialist.

Sources and selection criteria

We carried out an electronic search through PubMed, Ovid, and CINAHL using the search terms “multiple sclerosis” and “relapse”. We also searched personal reference archives and had discussions with colleagues. One author (CH) used information from three highly standardised patient education programmes developed at the Hamburg centre.

How is multiple sclerosis classified?

The clinical course of multiple sclerosis may vary.3 It is relapsing-remitting from onset in 85% of cases, characterised by episodes of neurological deficit (relapses) that recover (that is, remit), to varying degrees; if relapses are severe and frequent the term “rapidly evolving severe multiple sclerosis” is sometimes used. In the other 15% of cases, a gradual progression occurs from …

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