Patient handout

Multiple Sclerosis Flare

PRODUCTION

1. Your condition

This handout is for multiple sclerosis flare. Your care team identified this based on: new neurological deficit in known ms lasting ≥24h (aan 2024).

Other reasons your team may use this plan: acute monocular vision loss with painful eye movement + rapd (ontt 1992 pmid 1734247); sensory level / motor level / bowel-bladder dysfunction (aan 2024); acute brainstem / cerebellar syndrome — pivot for nmosd (aan 2024; wingerchuk 2015 pmid 26092914).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
methylprednisolone	1 g IV daily × 3–5 d	IV	daily × 3–5 d	ONTT (Beck NEJM 1992 PMID 1734247) — IV methylprednisolone shortens optic-neuritis recovery; oral prednisone alone increases recurrence
prednisone	1250 mg PO daily × 3–5 d	PO	daily × 3–5 d	Le Page (Lancet 2015) — oral methylprednisolone-equivalent 1250 mg/d non-inferior to IV (AAN 2024)

Plan: MS flare — acute relapse treatment (AAN 2024)

3. Your action plan

Use these zones to know what to do based on how you feel.

GREEN — Stable baseline (AAN 2024)

If you have:

No new neurologic symptoms
Function at baseline
No fever/infection

Do this:

Take DMT as prescribed
Heat avoidance (Uhthoff)
Hydration + sleep + exercise
Vitamin D supplementation if deficient
Annual MRI per MS clinic

YELLOW — Possible relapse — new symptom <24 h or with fever (AAN 2024)

If you have:

New neurologic symptom <24 h
Fever or infection (UTI, viral) — pseudo-relapse risk
Heat exposure with transient worsening (Uhthoff)

Do this:

Check temperature; if febrile, treat infection (avoid worsening triggers)
Hydrate, cool environment
Wait 24 h while monitoring
Contact MS clinic if symptoms persist >24 h or worsen

Call your provider if:

Symptom persists >24 h afebrile
Symptom worsens despite cooling/treatment
New severe symptom

RED — Relapse signs — call MS clinic / ED (AAN 2024)

If you have:

New visual loss (especially with painful eye movement) (ONTT PMID 1734247)
New limb weakness
New sensory level / bowel-bladder symptoms (transverse myelitis)
New brainstem symptoms (double vision, dysphagia, dysarthria, vertigo)
Symptoms persisting >24 h without fever

Do this:

Contact MS clinic urgently; if severe → ED
Bring DMT name + last dose
For severe optic neuritis (no light perception) or transverse myelitis: ED for STAT MRI + steroid pulse ± PLEX

Call your provider if:

Any red zone trigger — call MS clinic / ED

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

MS phenotype: acute monocular vision loss + RAPD + pain on eye movement; MRI orbit ± brain shows optic-nerve enhancement; high-dose IV methylprednisolone 1 g × 3–5 d per ONTT (Beck NEJM 1992 PMID 1734247)
MS phenotype: spinal-cord band-like deficit + sensory level + motor level + bowel/bladder dysfunction; MRI cord shows T2-hyperintense lesion; if ≥3 vertebral segments → NMOSD-suspected pivot (AAN 2024; Wingerchuk 2015 PMID 26092914)
MS phenotype: INO + ataxia + vertigo + dysarthria + dysphagia; MRI brainstem shows T2/gad-enhancing lesion; CAUTION — pivot for NMOSD area-postrema syndrome with intractable hiccups/vomiting (Wingerchuk 2015 PMID 26092914)
MS phenotype: severe flare unresponsive to IV methylprednisolone 1 g × 3–5 d by day 7–14; high-disability flare (high EDSS change, transverse myelitis, severe optic neuritis with no light perception) — plasmapheresis 5 cycles q48h (Apoly DS Magaña Neurology 2011 PMID 11309833 NEEDS_SOURCE_REVIEW)(life-threatening)
AQP4-IgG positive (live cell-based assay preferred) OR longitudinally extensive transverse myelitis ≥3 vertebral segments OR bilateral simultaneous optic neuritis OR area-postrema syndrome with intractable hiccups/vomiting (Wingerchuk 2015 PMID 26092914) — DIFFERENT MANAGEMENT
MOG-IgG positive (live cell-based assay preferred) OR bilateral optic neuritis with optic-nerve-head swelling OR cerebral cortical encephalitis with seizures OR ADEM-like presentation (Banwell 2023 PMID 36706773) — often monophasic
On natalizumab + JCV index >1.5 + >24 mo on therapy — PML risk > 1:1000 (AAN 2024)

5. Follow-up

MS clinic at 4–6 wk; rehab/PT/OT; symptomatic Rx (spasticity, fatigue, bladder); annual MRI brain ± cord; vaccine planning before B-cell depletion (AAN 2024)

6. Sources

Guideline: ECTRIMS 2024 Consensus on DMT Selection + AAN 2018 DMT Practice Guideline + 2017 McDonald Criteria (PMID 29275977; 2024 revision pending publication) + ONTT (Beck NEJM 1992 PMID 1734247) + Apoly DS (Magaña Neurology 2011 PMID 11309833 NEEDS_SOURCE_REVIEW) + NMOSD criteria 2015 (Wingerchuk Neurology 2015 PMID 26092914) + MOGAD criteria 2023 (Banwell Lancet Neurol 2023 PMID 36706773)