Synopsis
Recognise typical central demyelinating syndromes, confirm dissemination without overcalling non-specific MRI lesions, treat relapses safely, and organise disease-modifying, symptomatic and reproductive care through a specialist team.
- Multiple sclerosis is an immune-mediated inflammatory and neurodegenerative disorder diagnosed by a specialist using the 2024 revised McDonald criteria after reasonable alternatives are excluded; defined diagnostic routes do not always require the classic demonstration of dissemination in time.
- Typical attacks include painful monocular optic neuritis, partial transverse myelitis, a brainstem syndrome such as internuclear ophthalmoplegia, and a cerebellar or sensory syndrome developing over hours to days.
- A relapse is new or worsening neurological dysfunction lasting more than 24 hours without fever or infection, usually after at least a month of stability; transient heat-related worsening is a pseudo-relapse.
- MRI brain and often cervical or thoracic spinal cord imaging demonstrate characteristic lesion distribution and new inflammatory activity, but non-specific white-matter spots from migraine or vascular disease do not diagnose multiple sclerosis.
- Cerebrospinal-fluid-specific oligoclonal bands support intrathecal inflammation and can contribute to diagnostic criteria, while absence should prompt careful review rather than automatically exclude disease.
- Atypical severe bilateral optic neuritis, longitudinally extensive myelitis, area-postrema symptoms, encephalopathy or marked systemic inflammation raises aquaporin-4, MOG-associated, infectious, vascular or systemic inflammatory alternatives.
- Treat functionally significant relapse early with high-dose methylprednisolone after infection assessment; steroids shorten recovery but do not improve the long-term disability trajectory of that attack.
- Disease-modifying therapy selection depends on inflammatory activity, prognostic features, pregnancy plans, comorbidity, infection risk, monitoring burden and patient preference, not on an examination score alone.
- Symptom care addresses fatigue, spasticity, neuropathic pain, mobility, bladder and bowel dysfunction, cognition, mood, sexual health, sleep and work through coordinated multidisciplinary review.
- Live vaccines, latent infection screening, immunoglobulins, blood counts and reproductive timing vary by disease-modifying medicine; use current NHS England, NICE and product-specific safety pathways.
Key red flags
Rapid paraplegia, respiratory weakness, bilateral visual loss or disabling ataxia needs urgent admission and assessment for severe relapse and alternative inflammatory disease.
Investigation priorities
Demonstrate characteristic lesion morphology, dissemination and active enhancement.
Management branches
A person develops a new focal neurological deficit over hours or days.
- Localise the syndrome to optic nerve, brainstem, cerebellum or spinal cord, document objective signs and seek vascular, compressive, metabolic, infectious and antibody-mediated warning features.
- Arrange neurology review and protocol MRI of brain and relevant spine, adding cerebrospinal fluid and targeted mimic tests when criteria or phenotype require them.
- Avoid diagnosing multiple sclerosis from non-specific MRI spots or a symptom list alone; communicate diagnostic uncertainty and a concrete follow-up plan.
Key medicines
Methylprednisolone oralNICE recommends 0.5 g orally once daily for 5 days for a functionally significant acute relapse, prescribed through an appropriate relapse pathway.Exclude meaningful infection, discuss mood, sleep, glucose, gastrointestinal and bone risks, and never use lower-dose prolonged steroids as a substitute for this regimen.
Methylprednisolone intravenousNICE advises considering 1 g intravenously once daily for 3 to 5 days when oral treatment fails, is not tolerated or admission and monitoring are needed.Monitor glucose, blood pressure, psychiatric effects, infection and cardiac context; repeated courses should trigger disease-activity and cumulative-risk review.