Multiple sclerosis (MS) is a disease of the nervous system. In MS, there are defects in the communication between the brain and other parts of the body. MS effects can range from relatively mild in most cases to somewhat disabling to devastating. The symptoms may occur randomly (in flares) and then disappear. In the worst cases, a person with MS may be unable to walk, speak, or write.

During an MS flare, inflammation occurs in patches (called plaques) in any area of the nervous system. This inflammation causes damage to the myelin sheath. The myelin sheath is a fatty covering that protects nerve fibers in the brain and spinal cord. Myelin allows for the smooth, high-speed transmission of nerve signals between the brain, the spinal cord, and the rest of the body. When myelin is damaged, it may block or slow nerve signals, resulting in reduced or lost function.

Symptoms of MS include:

• Weakness in arms and legs
• Problems with balance and coordination
• Fatigue
• Tingling or numbness in any area
• Dizziness
• Blurred vision
• Pain
• Heat sensitivity
• Loss of bladder control
• Constipation
• Memory loss
• Difficulty in problem solving
• Mood disturbances
• Tremors
• Muscle spasms
• Speech problems
• Difficulty in swallowing

The exact cause of MS is unknown. Scientists think the disease is an autoimmune condition influenced by genetic and environmental factors. Other theories involve bacterial or viral factors.

People with the following conditions or characteristics are at higher risk for developing MS:

• First degree relatives with MS
• Age between 20 to 40
• Living in the northern latitudes for the first 15 years of life
• North European, North American, or Scandinavian ancestry
• Immune response genes
• Female gender
• Cigarette smoking
• Vitamin D deficiency

If you have symptoms associated with MS, you should see your health care provider. Your provider will:

• Ask detailed history
• Check for neurological problems
• Check your vision

The provider may order the following tests:

• Nerve function study test (evoked potential test)
• Lab tests, such as a cerebrospinal fluid (CSF) exam by lumbar puncture
• Imaging procedures, such as magnetic resonance imaging (MRI)
• Blood tests to rule out other conditions

Treatment Plan

There is no known cure for MS at this time. The primary goal of treatment is to reduce control symptoms and improve the quality of life.

Drug Therapies

Your health care provider may prescribe the following medications or a combination of the them:

• Steroids to reduce severity of attacks
• Beta interferon to decrease myelin destruction, reduce frequency and severity of attacks, and slow progression of disease
• Immunotherapy and cytokines are experimental therapies that may alter the course of the disease

Complementary and Alternative Therapies

Although no complementary or alternative therapy can cure, treat, or prevent MS, some strategies may improve symptoms of MS. However, some CAM therapies may interfere with conventional treatments. Inform all of your providers about any CAM therapies you are considering.

Nutrition and Supplements

These nutritional tips may help reduce symptoms:

• Eat a diet low in saturated fats.
• Eat a diet rich in fiber, particularly from whole grains, fruits, and vegetables. High-fiber diets are important for preventing constipation.
• Reduce consumption of red meat and include fish in your diet.
• Avoid alcohol.
• Stop smoking.
• Multivitamin diet is recommended.
• Epidemiologic studies have found a decreased incidence of MS in populations that had a low consumption of animal fats with a high consumption of cold-water fish.
• Mild to moderate exercise is recommended, at least 30 minutes daily for about 3 times a week.
• The Wahls Protocol. A dietary intervention for the treatment of MS and other autoimmune diseases. It was created by Terry Wahls, MD who herself had MS and was able to resolve the vast majority of her symptoms using a specialized dietary approach. She conducts research studies on this approach and it is gaining popularity. Discuss this option with your provider.

You may address nutritional deficiencies with the following:

• Omega-3 fatty acids. Fish oils have a high content of omega-3 fatty acids. Cold water fishes (for example, herring, salmon, or mackerel) are rich in omega-3 fatty acids. These have anti-inflammatory effects that maty be of benefit in MS.
• Evening primrose oil. Is rich in omega-6 fatty acids and is commonly used by MS patients. However, studies failed to prove any benefits of evening primrose oil for MS. Evening primrose oil may interfere with several medications.
• Multivitamin/multimineral. Containing the antioxidant Vitamins A, C, D, E, the B-vitamins and trace minerals, such as magnesium, calcium, zinc, and selenium, is generally recommended for people with MS.
• Vitamin D. Scientists have identified vitamin D deficiency as a possible contributing factor in the development of MS. Sun exposure and dietary sources of vitamin D during childhood and adolescence have been associated with a lower risk of developing MS. Vitamin D deficiency may be associated with a worsening of symptoms in early MS.
• Coenzyme Q10. May have antioxidant and anti-inflammatory effects. However, no studies have found coenzyme Q to be effective in MS. Coenzyme Q10 may interact with certain blood-thinning medications, such as wafarin (Coumadin) and others.
• N-acetyl cysteine. Has antioxidant effects and is used by some patients with MS. There are no studies demonstrating effects of N-acetyl cysteine in MS therapy. N-acetyl cysteine can interact with nitroglycerine.
• Acetyl-L-carnitine. May also have antioxidant effects. Some studies support the use of acetyl-L-carnitine in people with MS. However, Acetyl-L-carnitine has been suspected by some researchers to be unsafe for people with a history of seizure disorders. Speak with your doctor. before taking acetyl-L-carnitine.
• Probiotic supplement (containing Lactobacillus acidophilus). May help in the maintenance of gastrointestinal and immune health. Several studies suggest that probiotics may reduce inflammation in MS and could therefore be beneficial. However, probiotics are not appropriate for individuals who are severely immunosuppressed or who are on immunosuppressive drugs.
• Melatonin. Has antioxidant and anti-inflammatory effects. It was also shown to act as an immune regulator and some studies showed it may improve the course of MS by inhibiting demyelination and increasing remyelination. More studies are needed. Melatonin may interact with many medications, including sedatives, antidepressants, hormone medications, including birth control, and others.

Herbs

Herbs cannot cure multiple sclerosis or its complications. However, some herbs may help with certain symptoms, and can be used in addition to conventional therapy. Herbs can have side effects and can interact with other herbs, supplements, or medications. For these reasons, you should take herbs with care, under the supervision of a health care provider. Although with the exception of cannabis, clinical studies do not support herb use for MS treatment, some herbs used by people with MS include:

• Green tea (Camellia sinensis). May have antioxidant and immune effects. Some studies tested the effects of green tea compounds called catechins on the muscle weakness in MS. More research is necessary. Green tea consumed as a beverage is generally safe, however concentrated green tea extracts may have toxic effects on the liver.
• Rhodiola (Rhodiola rosea). May have antioxidant and immune effects. Some people with MS use Rhodiola to improve symptoms of fatigue and exercise intolerance, however there are no studies supporting it. Speak with your provider.
• Milk thistle (Silybum marianum) seed. Is sometimes used to improve symptoms of liver disease. Some studies suggested that silymarin, the main component of milk thistle seeds, has anti-inflammatory effects. Milk thistle may cause an allergic reaction in people who are sensitive to ragweed. Since milk thistle works on the liver, it can potentially interfere with a variety of medications. Speak with your physician.
• Bromelain (Ananus comosus). Is sometimes used for pain and inflammation. Bromelain is a mixture of protein-digesting enzymes that are found in the pineapple stem. In laboratory studies, bromelain had anti-inflammatory effects. Bromelain may increase the blood-thinning effects of certain medications, such as warfarin (Coumadin) and aspirin, and can interfere with certain medications, including some antibiotics.
• Ginkgo biloba. Has been used in traditional Chinese medicine for patients with cognitive impairment and dementia. Clinical studies found that Ginkgo biloba may reduce fatigue in people with MS. No other health benefits have been confirmed. Side effects include headaches and allergic reactions. Ginkgo biloba interacts with some medications, including blood-thinning drugs. Some laboratory studies found that animals exposed to Ginkgo biloba had increased risk for some cancers. Eating raw or roasted seeds of Gingko biloba may have dangerous side effects. Make sure you consult with your provider before taking Ginkgo biloba.
• Asian ginseng (Panax ginseng). Compounds found in ginseng may have effects on the immune system. Some studies found that ginseng may help treat the fatigue associated with MS, but more clinical results are needed. Ginseng may affect blood pressure and blood sugar and could interact with medications like anticoagulants. Talk to your provider before taking ginseng.
• Grape (Vitis vinifera) seed extract. Contains antioxidant substances and is used by some people with MS. There are no clinical studies supporting grape seed extract for therapy of symptoms of MS. Grape seed extract is generally safe, although its safety is not clear in people with bleeding disorders or who take blood-thinners. Check with your provider.
• Cannabis sativa. Has been demonstrated as an effective therapy for people with MS in multiple clinical studies. Cannabinoids (either as oral extract, spray, or synthetic tetrahydrocannabinol) are currently among the clinically recommended therapies for the management of pain and spasticity in MS. Recommendations do not include smoked cannabis (marijuana), on which study results are unclear. Side effects are generally mild for the short-term use. In the long-term, due to its psychoactive properties, the safety of cannabinoid use is unclear. In the United States, the legal status of specific medical cannabis preparations varies among different states, and the FDA has not approved any product containing or derived from botanical marijuana for any indication.

Homeopathy

No clinical studies found homeopathic remedies to be effective in MS therapy. However, some people with MS use a homeopathy approach together with conventional therapy for some of their symptoms. Remedies include:

• Carboneum sulphuratum
• Causticum
• Lathyrus sativus
• Phosphorus

Physical Medicine

• Exercise therapy. Physical exercise improves several symptoms of MS. Exercise can decrease complications of muscle weakness and spasticity. Exercise also improves general health and well-being. Aquatic exercises may be of special use to people with MS. Exercise is generally safe and well tolerated.
• Acupuncture. Acupuncture may alleviate symptoms of MS. Small studies showed benefits of acupuncture in patients with MS, but larger and higher quality clinical studies are necessary to test its efficacy and safety.
• Massage. Massage could be helpful for maintaining flexibility and reducing spasticity, as well as improving overall sense of well-being.
• Yoga. Studies on the effect of yoga on MS symptoms were inconsistent. Some studies noted beneficial effects on mobility, fatigue, and quality of life. Other studies did not find any additional benefit compared to other forms of exercise. Yoga is considered generally safe.

At the beginning of MS, about 85% of people experience attacks separated by periods of remission, during which symptoms subside. About half of these people have a chronic, progressive worsening after 10 to 15 years. About 15% of people experience a chronic progressive worsening from the initial onset.

Most people with MS live for 30 years or more with the disease. Most people with MS are active and function at work with little disability. The amount of disability and discomfort depends on:

• How often and severe the attacks are
• The part of the nervous system that is affected by each attack

Most people return to normal or near-normal function between attacks. Over time, there is greater loss of function with less improvement between attacks.

Bladder, bowel and sexual dysfunction are common among this population. Other complications may include:

• Difficulty swallowing
• Pressure sores
• Osteoporosis
• Difficulty thinking
• Depression
• Urinary tract infections
• Side effects of medicines used to treat the condition

People with MS will need lifelong monitoring, especially during flare-ups.

Abrams DI. The therapeutic effects of Cannabis and cannabinoids: An update from the National Academies of Sciences, Engineering and Medicine report. Eur J Intern Med. 2018;49:7-11. PMID: 29325791 www.ncbi.nlm.nih.gov/pubmed/29325791.

Anderson G, Rodriguez M. Multiple sclerosis: the role of melatonin and N-acetylserotonin. Mult Scler Relat Disord. 2015;4(2):112-123. PMID: 25787187 www.ncbi.nlm.nih.gov/pubmed/25787187.

Bagur MJ, Murcia MA, Jiménez-Monreal AM, et al. Influence of diet in multiple sclerosis: a systematic review. Adv Nutr. 2017;8(3):463-472. PMID: 28507011 www.ncbi.nlm.nih.gov/pubmed/28507011.

Bavarsad Shahripour R, Harrigan MR, Alexandrov AV. N-acetylcysteine (NAC) in neurological disorders: mechanisms of action and therapeutic opportunities. Brain Behav. 2014;4(2):108-122. PMID: 24683506 www.ncbi.nlm.nih.gov/pubmed/24683506.

Cramer H, Lauche R, Azizi H, Dobos G, Langhorst J. Yoga for multiple sclerosis: a systematic review and meta-analysis. PLoS One. 2014;9(11):e112414. PMID: 25390344 www.ncbi.nlm.nih.gov/pubmed/25390344.

Etemadifar M, Sayahi F, Abtahi SH, et al. Ginseng in the treatment of fatigue in multiple sclerosis: a randomized, placebo-controlled, double-blind pilot study. Int J Neurosci. 2013;123(7):480-486. PMID: 23301896 www.ncbi.nlm.nih.gov/pubmed/23301896.

Fabian MT, Krieger SC, Lublin FD. Multiple sclerosis and other inflammatory demyelinating diseases of the central nervous system. In: Daroff RB, Jankovic J, Mazziotta JC, Pomeroy SL, eds. Bradley's Neurology in Clinical Practice. 7th ed. Philadelphia, PA: Elsevier; 2016:chap 80.

Farzaei MH, Shahpiri Z, Bahramsoltani R, et al. Efficacy and tolerability of phytomedicines in multiple sclerosis patients: a review. CNS Drugs. 2017;31(10):867-889. PMID: 28948486 www.ncbi.nlm.nih.gov/pubmed/28948486.

Glenn JD, Mowry EM. Emerging concepts on the gut microbiome and multiple sclerosis. J Interferon Cytokine Res. 2016;36(6):347-357. PMID: 27145057 www.ncbi.nlm.nih.gov/pubmed/27145057.

Heine M, van de Port I, Rietberg MB, van Wegen EE, Kwakkel G. Exercise therapy for fatigue in multiple sclerosis. Cochrane Database Syst Rev. 2015;(9):CD009956. PMID: 26358158 www.ncbi.nlm.nih.gov/pubmed/26358158.

Karpatkin HI, Napolione D, Siminovich-Blok B. Acupuncture and multiple sclerosis: a review of the evidence. Evid Based Complement Alternat Med. 2014;2014:972935. PMID: 25045394 www.ncbi.nlm.nih.gov/pubmed/25045394.

Rathnavelu V, Alitheen NB, Sohila S, Kanagesan S, Ramesh R. Potential role of bromelain in clinical and therapeutic applications. Biomed Rep. 2016;5(3):283-288. PMID: 27602208 www.ncbi.nlm.nih.gov/pubmed/27602208.

Riccio P, Rossano R. Nutrition facts in multiple sclerosis. ASN Neuro. 2015;7(1). pii: 1759091414568185. PMID: 25694551 www.ncbi.nlm.nih.gov/pubmed/25694551.

Sá MJ. Exercise therapy and multiple sclerosis: a systematic review. J Neurol. 2014;261(9):1651-1661. PMID: 24263406 www.ncbi.nlm.nih.gov/pubmed/24263406.

Shinto L, Yadav V, Mischley LK, Bourdette DN. Multiple sclerosis. In: Pizzorno JE, Murray MT, eds. Textbook of Natural Medicine. 4th ed. St Louis, MO: Elsevier Churchill Livingstone; 2013:chap 191.

Tejani AM, Wasdell M, Spiwak R, Rowell G, Nathwani S. Carnitine for fatigue in multiple sclerosis. Cochrane Database Syst Rev. 2012;(5):CD007280. PMID: 22592719 www.ncbi.nlm.nih.gov/pubmed/22592719.

Tur C. Fatigue management in multiple sclerosis. Curr Treat Options Neurol. 2016;18(6):26. PMID: 27087457 www.ncbi.nlm.nih.gov/pubmed/27087457.

Wurtman R. Multiple sclerosis, melatonin, and neurobehavioral diseases. Front Endocrinol (Lausanne). 2017;8:280. PMID: 29109699 www.ncbi.nlm.nih.gov/pubmed/29109699.

Yadav V, Bever C Jr, Bowen J, et al. Summary of evidence-based guideline: complementary and alternative medicine in multiple sclerosis: report of the guideline development subcommittee of the American Academy of Neurology. Neurology. 2014;82(12):1083-1092. PMID: 24663230 www.ncbi.nlm.nih.gov/pubmed/24663230.