How Multiple Sclerosis Is Treated

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If you've been diagnosed with multiple sclerosis (MS), it's time to start exploring treatment options. You've got a lot of them, everything from disease-modifying therapies and drugs that help manage symptoms to rehabilitation strategies and lifestyle changes that will help you live better.

There is no cure for MS—yet—but you can live well with this disease. A big part of that is working with your doctor to find the treatment regimen that's best for you.

What is Multiple Sclerosis
 Verywell / Nusha Ashjaee

Prescriptions

Prescription medications for MS fall into two broad categories: disease-modifying therapies (DMTs), which slow the progression of the disease, and drugs that help manage your symptoms.

Disease-Modifying Therapies

DMTs are an important first step to treating your MS. While they won't directly help your symptoms, they work behind the scenes to slow down your condition.

Studies on disease-modifying medications for MS suggest that they not only decrease the number of relapses you have, but also make those relapses less severe. In addition, disease-modifying medications are believed to decrease the number and size of lesions (as seen on MRIs of the brain and spinal cord) and slow the overall progression of MS.

Because of the beneficial long-term impact DMTs can have, the National MS Society strongly advises people to begin these drugs as soon as possible after diagnosis. The earlier you start, the better chance you have of reducing your symptom load and preserving your function.

DMTs come in three different forms: injections, oral therapies, and IV infusions. Many DMTs have been FDA-approved to treat relapsing forms of MS in adults, which includes relapsing-remitting MS and secondary progressive MS that involves relapses.

Many DMT drugs are also approved to treat clinically isolated syndrome—this includes all of the injectable medications, many of the oral drugs, and two of the infusion drugs: Ocrevus (ocrelizumab) and Tysabri (natalizumab).

Ocrevus (ocrelizumab) is also approved to treat primary progressive MS, and Novantrone (mitoxantrone) is approved for secondary-progressive MS, progressive-relapsing MS, and worsening relapsing-remitting MS.

Injections

Injectable DMTs are injected either into a muscle (intramuscular) or underneath the skin into your fatty tissues (subcutaneous).

Beta Interferon Drugs

Interferons are proteins that your immune system creates in order to combat a viral infection. Five of the injectable medications used for MS are beta interferon drugs:

  • Avonex, Rebif (interferon beta-1a)
  • Betaseron, Extavia (interferon beta-1b)
  • Plegridy (peginterferon beta-1a)

In people with MS, it's believed that interferon therapies alter the autoimmune response, leading to fewer attacks on the myelin in your brain and spinal cord and, thus, fewer MS symptoms.

Interferon therapies are generally well tolerated but may cause pain or redness at the skin site where the medicine is injected. In addition, some people experience flu-like symptoms, but that usually stops happening as treatment continues.

Depending on the specific interferon you are taking, your doctor may monitor bloodwork (like liver or blood cell tests) or ask you questions about your medical history before prescribing it. For instance, your doctor may ask if you have a history of depression, which can worsen on interferon therapy.

Copaxone, Glatopa

Also in the injectable category are Copaxone and Glatopa (glatiramer acetate). Scientists believe glatiramer acetate mimics a protein found in myelin and distracts your immune system from attacking the real thing.

A common side effect of Copaxone and Glatopa is a reaction at the injection site, similar to interferon therapy. Rotating injection sites and using a warm compress prior to injecting can help minimize the reaction.

Also, about 16% of people who take Copaxone or Glatopa experience a racing heart or anxiety after injection. While this can be scary, it usually goes away within 15 minutes and doesn't have any long-term consequences.

Oral Therapies

Oral DMTs are a good option for people who can't tolerate or don't benefit from injectable DMTs.

Gilyena (fingolimod) is a pill that you take once a day. It mainly works by trapping certain immune cells in the lymph nodes, which means they can't circulate and create lesions on your brain and spinal cord. Gilenya is also the first and only FDA-approved medication to treat children and adolescents age 10 years and older with MS.

Common side effects of Gilyena include headache, diarrhea, cough, sinus inflammation, and pain in the back, stomach, arms, or legs.

Mayzent (siponimod) and Zeposia (Ozanimod) are newer DMTs that work similarly to Gilyena. They are both tablets taken once a day. However, when you first start either one of these drugs, you have to work up to the regular dosage. Make sure you understand and follow the dosing directions exactly, and ask your doctor or pharmacist any questions you may have.

Common side effects of Mayzent include headache and high blood pressure. For Zeposia, some common side effects include back pain, low blood pressure when you stand up (called orthostatic hypotension), and high blood pressure.

All three drugs—Gilyena, Mayzent, and Zeposia—can cause more serious adverse effects like blurry vision, breathing or liver problems, and infections. They sometimes slow down the heart, so you may need special testing before you start treatment or be monitored in a healthcare facility after your first dose.

Tecfidera (dimethyl fumarate) is a pill that's taken twice daily. It activates a response in your body that's designed to protect cells that are in distress. Exactly how this works in someone with MS is unclear.

Common side effects of Tecfidera are flushing, nausea, diarrhea, and stomach pain. Serious adverse effects include a severe allergic reaction, the development of progressive multifocal leukoencephalopathy (PML, a potentially fatal infection of the brain linked to the JC virus), and suppression of your body's infection-fighting cells.

Vumerity (diroximel fumarate) is an oral capsule taken twice a day. The exact mechanism remains unknown, although experts suspect it may work by reducing oxidative stress, which helps protect against damage within the central nervous system.

Vumerity is chemically similar to Tecfidera, which is why they share common side effects like flushing, abdominal pain, diarrhea, and nausea. People appear to tolerate Vumerity better than Tecfidera, especially when it comes to the gastrointestinal side effects.

Bafiertam (monomethyl fumarate) is another oral DMT that is similar to Tecfidera and Vumerity. It is also taken twice per day and has similar side effects, most commonly flushing and nausea. Rare but serious side effects include allergic reactions, PML, decreased ability to fight infections, liver problems, and shingles.

Aubagio (teriflunomide) is taken once daily and works by suppressing the immune system, so it can predispose people to infections. It may also cause headaches, hair thinning, diarrhea, nausea, or abnormal liver blood tests.

Since Aubagio can cause liver failure, your doctor will check your liver blood tests prior to starting the medication and then periodically afterward. Aubagio is also contraindicated for pregnancy. Because Aubagio can cause major birth defects, if you are a woman of reproductive age, your doctor might require you to use a reliable contraception method.

Mavenclad (cladribine) is for highly active relapsing forms of MS. The dosage schedule is unusual, with short periods of taking pills spread out over two years. This drug temporarily reduces your levels of T cells and B cells, but without continuously suppressing the immune system.

Possible side effects include herpes zoster virus infection, rashes, hair loss, and reduced neutrophil count (a type of white blood cell). It may also lower your body's resistance to infections and cancer. People with kidney problems and those who are pregnant or breastfeeding shouldn't take Mavenclad.

Infusions

A drug infusion is delivered through an IV needle or catheter, and you have to go sit at a healthcare facility to receive it. These DMTs are typically for more severe cases, and they can come with severe side effects.

Lemtrada (alemtuzumab) is infused for five days in a row, and then three days in a row one year later. Due to the fact that there are a number of FDA warnings linked to Lemtrada, it can only be prescribed through a special program and is reserved for people who've had an inadequate response to at least two other DMTs.

Novantrone (mitoxantrone) is a chemotherapy drug that is given every three months. In addition to treating relapsing forms of MS, mitoxantrone can also be used to treat secondary progressive MS. Mitoxantrone can cause heart damage, so it can only be given a limited number of times. It has also been linked to the development of acute myeloid leukemia.

Tysabri (natalizumab) is given every 28 days. It can only be administered in an approved infusion center due to the risk of developing PML. Some common side effects of Tysabri include infections (of the lungs, nose and throat, and urinary tract), headache, and joint and stomach-area pain.

Ocrevus (ocrelizumab) is one of the newer FDA-approved MS infusion therapies and the first ever to be approved for primary progressive MS. It's also approved for relapsing MS. Ocrevus is given every six months and works by essentially deactivating a type of B cell, which is one of the immune cells believed to play a role in the damage and destruction of myelin.

If you are receiving Ocrevus, you will be monitored for signs of a serious infusion reaction (e.g., flushing, itchy skin, or throat irritation) during your infusion and for at least one hour after the infusion.

Drugs for Treating Fatigue

Fatigue is among the most pervasive and ubiquitous symptoms of MS. Going well beyond "tired," it's a form of brutal, debilitating exhaustion that can make simple activities like getting dressed in the morning or concentrating on a movie difficult or even impossible.

Prescription medications that are sometimes used to help people with MS feel alert and be productive include:

Drugs for Treating Pain

Nerve-related pain (called neuropathic pain or neuropathy) isn't like the pain of an acute injury, such as a broken arm or strained muscle. You can't treat it effectively with typical over-the-counter pain relievers or even prescription pain drugs like Vicodin (hydrocodone). Nerve pain requires drugs that target overactivity in the nervous system.

The neuropathy of MS is generally treated with:

  • Anti-seizure drugs, such as Lyrica (pregabalin) and Neurontin (gabapentin)
  • Certain antidepressants

Spasticity (muscle spasms and rigidity) can also cause a lot of pain in people with MS. Muscle relaxants may help.

Drugs for Other MS Symptoms

You may be prescribed other drugs for your specific symptoms, such as cognitive dysfunction, sexual dysfunction, depression, or problems with urination. It all depends on which systems in your body are affected by MS and what symptoms are most bothersome to you.

Lifestyle

Lifestyle changes may play a larger role in managing MS than you realize. While they're certainly no replacement for DMTs or other medications, they can have a big impact.

Diet

Finding the diet that best alleviates your symptoms takes experimentation. It's crucial that you involve your healthcare team in your decisions and pay close attention to any changes in your symptoms or overall well-being.

You can find a lot of advice out there about what diet is best for MS, and much of it is conflicting. What's true of all the diets is that their effectiveness varies greatly from person to person. None of them have been researched enough to determine their effects on the course or symptoms of MS.

Diets that some people say help with MS include:

  • Paleolithic or Paleo diet
  • Swank diet 
  • Mediterranean diet
  • Ketogenic diet 
  • Fasting mimicking diet

Some of these diets have been researched, but the quality of some studies has been called into question by the medical community. Consult with your doctor to make sure any dietary changes you want to make are okay for you.

The National MS Society recommends a well-balanced diet that is rich in fiber and low in saturated fat. This type of nutrition plan is also heart-healthy and may help you lose weight or maintain a healthy weight.

The basic guidelines suggest eating:

  • A variety of whole grains, vegetables, and fruits
  • Lean sources of protein
  • Healthy fats, such as avocados, almonds, and walnuts

Meanwhile, avoid or strictly limit processed foods, and cut back on sugar and salt.

When you make dietary changes, it's a good idea to keep a log of what you're eating and how you feel so you can look for patterns.

Two dietary supplements—vitamin D and probiotics—have some evidence as MS treatments. Your doctor or a nutritionist can help you determine appropriate dosages for you.

Healthy Sleep Habits

A vast majority of people with MS experience some kind of sleep disturbance. Often, it's MS symptoms that keep you from sleeping well. The disease can also directly contribute to sleep disorders such as sleep apnea, insomnia, and narcolepsy. Poor sleep may also be a side effect of medications.

As complicated as all that is, it's important for you to first work with your doctor to figure out what the culprits are.

Meanwhile, you may be able to get better sleep by following healthy sleep habits, which are often called sleep hygiene. This includes:

  • Getting up and going to sleep at a consistent time
  • Making your sleep environment comfortable and relaxing
  • Limiting activity in the bedroom to sleep and sex
  • Avoiding caffeine and other stimulants as well as alcohol for four to six hours before bedtime

A sleep log may help you spot problems you would otherwise miss. If you struggle with establishing better habits, you may also benefit from cognitive behavioral therapy.

The Nap Conundrum

Sleep experts say napping can lead to tossing and turning at night. When you have a disease that saps your energy, though, you may depend on them to get through the day. Keeping a sleep log can help you determine whether or not taking naps (or the timing of them) affects your ability to sleep at night.

Complementary and Alternative Medicine

A range of complementary and alternative medicine (CAM) treatments have some evidence backing their use for treating MS. Again, these aren't meant to replace standard treatments, but they may help alleviate symptoms and keep you functioning.

Depending on what your symptoms are and how they impact your life, you may benefit from physical or occupational therapy. A therapist can teach you how to perform daily tasks in different ways or re-train muscles that haven't been used due to pain.

Moderate exercise, designed by a physical therapist and geared to your fitness level, can help as well.

Many people with MS also explore mind-body therapies. These may help with some of your physical symptoms, but they can also help with your overall health, stress management, well-being, and morale.

Popular mind-body approaches include progressive muscle relaxation therapy, yoga, and mindfulness meditation.

Experimental Treatments

As researchers learn more about MS, different types of therapies are emerging. More medications similar to Tysabri, called monoclonal antibodies, are currently being explored.

Other therapies, like estriol and stem cell transplantation, are more controversial—mostly because there are no large scientific studies to back up their use.

Estriol

Estriol is a type of estrogen that's only produced in pregnancy. It's the suspected reason that the risk of relapse drops by 70% in the third trimester of pregnancy.

Research on estriol for treating MS is moving forward and, so far, results are promising. Studies show the hormone may reduce pro-inflammatory cytokines, which are specialized immune system cells that cause inflammation in autoimmune and neurodegenerative diseases such as MS.

A 2016 phase 2 trial found that estriol plus glatiramer acetate (the drug in Copaxone and Glatopa) reduced relapse rates in women with MS and was well tolerated for the two years of the study.

This study and others like it may pave the way for phase 3 trials, which will provide a clearer picture of what estriol may have to offer.

Stem Cell Transplantation

Stem cells are an intriguing option because they could, in theory, build you a new immune system—one that doesn't target your myelin.

A 2016 Canadian study in Lancet involved 24 people with aggressive relapsing-remitting or secondary-progressive MS, sustained disability, and very poor prognoses. Three years after stem cell transplantation, 17 of them (70%) had no MS disease activity, meaning:

  • No new relapses
  • No new lesions, according to MRI results
  • No evidence of disease progression

In addition, seven and a half years after the transplant, 40% of participants had improvement in their MS-related disability.

That's all really promising, but there's a downside. For the process to work, the immune system has to be either wiped out or suppressed.

In the Lancet study, it was fully wiped out. Because of that, one participant died of infection. Another developed severe liver-related problems and was hospitalized for an extended period of time. Others experienced side effects such as neutropenic fever and chemotherapy-related toxicities.

In a 2015 study published in JAMA, participants' immune systems were suppressed rather than obliterated. Results were similar to the Lancet study, but with significantly fewer worrisome side effects, and no deaths or serious infections.

Large, randomized clinical studies are still needed to confirm the safety and effectiveness of stem cell treatment for MS.

A Word From Verywell

The goal of treatment is to strike a delicate balance between slowing down your MS, minimizing side effects, and maximizing how you feel. Remember that each case of MS is unique, so what works for someone else may not be best for you. And as your disease progresses or improves after a relapse, your symptoms and treatment decisions may change. Be patient and flexible, expect change, and keep lines of communication open between you and your healthcare team.

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