Multiple sclerosis

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Last reviewed: 8 Apr 2025

Last updated: 21 Mar 2025

Multiple sclerosis (MS) is a demyelinating central nervous system condition clinically defined by two episodes of neurologic dysfunction (brain, spinal cord, or optic nerves) that are separated in space and time.

Classically presents in white women, ages between 20 and 40 years, with temporary visual or sensory loss. However, it may affect either sex and any age or ethnic group, and may have variable neurologic symptom location and/or duration.

The patient may have subtle changes in vision, ambulation, and reflexes on examination that provide evidence of previous attacks (which may not have been noticed by the patient).

Magnetic resonance imaging (MRI) of both the brain and spinal cord is important in diagnosis. Brain MRI is sensitive, but very susceptible to over-interpretation in the absence of clinical correlation. Spinal cord MRI is abnormal less often, but lends greater specificity when present with brain lesions.

Treatment of MS can be divided into three parts: treatment of the acute attack; prevention of future attacks by reducing triggers and use of disease-modifying therapies; and symptomatic treatments of neurologic difficulties such as spasticity, pain, fatigue, and bladder dysfunction.

Definition

Multiple sclerosis (MS) is defined as an inflammatory demyelinating disease characterized by the presence of episodic neurologic dysfunction in at least two areas of the central nervous system (brain, spinal cord, and optic nerves) separated in time and space.[1]

BMJ talk medicine: multiple sclerosis Opens in new window

History and exam

Key diagnostic factors

visual disturbance in one eye
peculiar sensory phenomena

Full details

Other diagnostic factors

female sex
age 20-40 years
foot dragging or slapping
leg cramping
fatigue
urinary frequency
bowel dysfunction
spasticity/increased muscle tone
increased deep tendon reflexes
imbalance/incoordination
pale optic disk or noncorrectable visual loss
incorrect responses to Ishihara color blindness test plates
abnormal eye movements

Full details

Risk factors

female sex
family history of MS
northern latitude
genetic factors
smoking
vitamin D deficiency
autoimmune disease
Epstein-Barr virus
overweight/obesity in children and adolescents

Full details

Diagnostic tests

1st tests to order

MRI - brain
MRI - spinal cord
CBC
comprehensive metabolic panel
thyroid-stimulating hormone
vitamin B12

Full details

Tests to consider

antibody testing for neuromyelitis optica spectrum disorders (NMOSD)
cerebrospinal fluid evaluation
evoked potentials

Full details

Treatment algorithm

ACUTE

acute relapse affecting function

ONGOING

relapsing-remitting MS

secondary progressive MS

primary progressive MS

Contributors

Authors

Mary Alissa Willis, MD

Associate Professor and Chair

Department of Neurology

University of Mississippi Medical Center

Jackson

Disclosures

MAW has been compensated for Speakers' Bureau participation with Alexion, Biogen, Bristol-Myers Squibb, Genzyme, and Genentech, and advisory board participation with Alexion, Biogen, Greenwich Biosciences, Genentech, and Horizon.

Acknowledgements

Dr Mary Alissa Willis would like to gratefully acknowledge Dr Lael A. Stone, a previous contributor to this topic. We have since been made aware that Dr Stone is deceased.

Peer reviewers

Alex Rae-Grant, MD

Project Leader for Neurology

Neurological Institute

Cleveland Clinic

Cleveland

Disclosures

ARG declares that he has no competing interests.

Sarah A. Morrow, MD, FRCPC, MS

Associate Professor of Neurology

Department of Clinical Neurological Sciences

London Health Sciences Centre

University Hospital

Ontario

Canada

Disclosures

SAM declares that she has no competing interests.

Marcelo Kremenchutzky, MD

Director

The London Multiple Sclerosis Clinic

Associate Professor

Schulich School of Medicine

University of Western Ontario

Neurologist

Clinical Neurological Sciences Department

University Hospital

London Health Sciences Centre

Ontario

Canada

Disclosures

MK declares that he has no competing interests.

Abhijit Chaudhuri, DM, MD, PhD, FACP, FRCPGlasg, FRCPLond

Consultant Neurologist

Department of Neurology

Queen’s Hospital

Romford

Disclosures

AC declares that he has no competing interests.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

Lublin FD, Reingold SC, Cohen JA, et al. Defining the clinical course of multiple sclerosis: the 2013 revisions. Neurology. 2014 Jul 15;83(3):278-86.Full text Abstract

Wattjes MP, Ciccarelli O, Reich DS, et al. 2021 MAGNIMS-CMSC-NAIMS consensus recommendations on the use of MRI in patients with multiple sclerosis. Lancet Neurol. 2021 Aug;20(8):653-670.Full text Abstract

Thompson AJ, Banwell BL, Barkhof F, et al. Diagnosis of multiple sclerosis: 2017 revisions of the McDonald criteria. Lancet Neurol. 2018 Feb;17(2):162-73. Abstract

Kantarci O, Wingerchuk D. Epidemiology and natural history of multiple sclerosis: new insights. Curr Opin Neurol. 2006 Jun;19(3):248-54. Abstract

Filippi M, Rocca MA, Arnold DL, et al. Use of imaging in multiple sclerosis. In: Gilhus NE, Barnes MP, Brainin M, eds. European handbook of neurological management: volume 1, 2nd ed. Chichester, UK: Wiley-Blackwell; 2011:35-51.Full text

Tramacere I, Del Giovane C, Salanti G, et al. Immunomodulators and immunosuppressants for relapsing-remitting multiple sclerosis: a network meta-analysis. Cochrane Database Syst Rev. 2015 Sep 18;(9):CD011381.Full text Abstract

Scolding N, Barnes D, Cader S, et al. Association of British Neurologists: revised (2015) guidelines for prescribing disease-modifying treatments in multiple sclerosis. Pract Neurol. 2015 Aug;15(4):273-9.Full text Abstract

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

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Multiple sclerosis

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic tests

1st tests to order

Tests to consider

Treatment algorithm

acute relapse affecting function

relapsing-remitting MS

secondary progressive MS

primary progressive MS

Contributors

Authors

Mary Alissa Willis, MD

Disclosures

Acknowledgements

Peer reviewers

Alex Rae-Grant, MD

Disclosures

Sarah A. Morrow, MD, FRCPC, MS

Disclosures

Marcelo Kremenchutzky, MD

Disclosures

Abhijit Chaudhuri, DM, MD, PhD, FACP, FRCPGlasg, FRCPLond

Disclosures

References

Key articles

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials

Guidelines

Patient information

Videos

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

Log in to access all of BMJ Best Practice