Multiple Sclerosis

Issue

Vol. 2 No. 2 (2025)

Date Log

Submitted
March 14, 2025
Accepted
April 1, 2025
Published
May 12, 2025

Multiple Sclerosis - Causes, Diagnosis and Treatment

https://doi.org/10.69512/ajphi.v2i2.98
Gauri Adhikari, MD
Department of Internal Medicine, Washington University/Consortium at Missouri Baptist Medical Center, St. Louis, MO, USA
Aakriti Karki, MD
Jalalabad Ragib Rabeya Medical College and Hospital, Sylhet, Bangladesh
https://orcid.org/0009-0007-4024-1617

Corresponding Author(s) : Gauri Adhikari, MD

gauryadhikary@gmail.com

The American Journal of Patient Health Info, Vol. 2 No. 2 (2025)

Abstract


  1. Multiple sclerosis affects the brain and spine, causing problems like tiredness, difficulty walking, and vision issues.

  2. This condition primarily affects women, and it usually starts when people are between 20 and 40 years old.

  3. It affects people differently; some might feel tired, while others have trouble walking or see things blurry.

  4. If a woman has multiple sclerosis, pregnancy can be tricky. While symptoms may get better during pregnancy, there is a slight chance that multiple sclerosis may get worse after giving birth.

  5. While there's no cure for multiple sclerosis, eating well, staying active, managing stress, and not smoking can help people feel better and live healthier lives.

Keywords

multiple sclerosis autoimmune neuroinflammation
Adhikari, MD, G., & Karki, MD, A. (2025). Multiple Sclerosis - Causes, Diagnosis and Treatment. The American Journal of Patient Health Info, 2(2). https://doi.org/10.69512/ajphi.v2i2.98
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References
  1. Zainab SR, Khan JZ, Tipu MK, Jahan F, Irshad N. Decoding multiple sclerosis: Unravelling the complexities of pathogenesis, progression, mechanisms and therapeutic innovations. Neuroscience [Internet]. 2024;S0306-4522(24)007358. Available from: https://pubmed.ncbi.nlm.nih.gov/39709058/
  2. Faissner, S., Plemel, J.R., Gold, R. and Yong, V.W. (2019). Progressive multiple sclerosis: from pathophysiology to therapeutic strategies. Nature Reviews Drug Discovery, [online] 18(12). Available from: https://pubmed.ncbi.nlm.nih.gov/31399729/
  3. McGinley MP, Goldschmidt CH, Rae-Grant AD. Diagnosis and Treatment of Multiple Sclerosis. JAMA [Internet]. 2021 Feb 23;325(8):765–79. Available from: https://jamanetwork.com/journals/jama/article-abstract/2776694
  4. McKay KA, Kwan V, Duggan T, Tremlett H. Risk Factors Associated with the Onset of Relapsing-Remitting and Primary Progressive Multiple Sclerosis: A Systematic Review. BioMed Research International [Internet]. 2015;2015:1–11. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4329850/
  5. Olsson T, Barcellos LF, Alfredsson L. Interactions between genetic, lifestyle and environmental risk factors for multiple sclerosis. Nature Reviews Neurology. 2016 Dec 9;13(1):25–36. Available from:https://pubmed.ncbi.nlm.nih.gov/27934854/
  6. Hedström AK, Hillert J, Olsson T, Alfredsson L. Factors affecting the risk of relapsing-onset and progressive-onset multiple sclerosis. Journal of Neurology, Neurosurgery & Psychiatry [Internet]. 2021 Oct 1 [cited 2022 Oct 3];92(10):1096–102. Available from: https://jnnp.bmj.com/content/92/10/1096
  7. Alfredsson L, Olsson T. Lifestyle and Environmental Factors in Multiple Sclerosis. Cold Spring Harbor Perspectives in Medicine [Internet]. 2018 May 7;9(4):a028944. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6444694/
  8. Cree BAC, Arnold DL, Chataway J, Chitnis T, Fox RJ, Pozo Ramajo A, et al. Secondary Progressive Multiple Sclerosis. Neurology [Internet]. 2021 Jun 4;97(8):378–88. Available from: https://n.neurology.org/content/97/8/378
  9. Antel J, Antel S, Caramanos Z, Arnold DL, Kuhlmann T. Primary progressive multiple sclerosis: part of the MS disease spectrum or separate disease entity? Acta Neuropathologica. 2012 Feb 11;123(5):627–38. Available from: https://pubmed.ncbi.nlm.nih.gov/22327362/
  10. Confavreux C, Vukusic S. Natural history of multiple sclerosis: a unifying concept. Brain [Internet]. 2006 Jan 16;129(3):606–16. Available from: https://academic.oup.com/brain/article/129/3/606/390915
  11. Kraker JA, Xu SC, Flanagan EP, Foster R, Wang F, Chen JJ. Ocular Manifestations of Multiple Sclerosis: A Population-Based Study. Journal of neuro-ophthalmology : the official journal of the North American Neuro-Ophthalmology Society [Internet]. 2024 Jan;44(2):157–61. Available from: https://pubmed.ncbi.nlm.nih.gov/38457238/
  12. Ford H. Clinical presentation and diagnosis of multiple sclerosis. Clinical Medicine [Internet]. 2020 Jul;20(4):380–3. Available from: https://pubmed.ncbi.nlm.nih.gov/32675142/
  13. Dejan Jakimovski, Weinstock-Guttman B, Roy S, Jaworski M, Hancock LM, Nizinski A, et al. Cognitive Profiles of Aging in Multiple Sclerosis. Frontiers in Aging Neuroscience. 2019 May 10;11. Available from: https://pubmed.ncbi.nlm.nih.gov/31133845/
  14. Miller D, Barkhof F, Montalban X, Thompson A, Filippi M. Clinically isolated syndromes suggestive of multiple sclerosis, part I: natural history, pathogenesis, diagnosis, and prognosis. The Lancet Neurology. 2005 May;4(5):281–8. Available from: https://pubmed.ncbi.nlm.nih.gov/15847841/
  15. Rimkus C de M, Nucci MP, Avolio IB, Apóstolos-Pereira SL, Callegaro D, Wagner MB, et al. Atrophy Patterns in Patients With Multiple Sclerosis With Cognitive Impairment, Fatigue, and Mood Disorders. Neurology [Internet]. 2024 Winter;103(12):e210080. Available from: https://pubmed.ncbi.nlm.nih.gov/39571119/
  16. Hartung HP, Graf J, Aktas O, Mares J, Barnett MH. Diagnosis of multiple sclerosis: revisions of the McDonald criteria 2017 - continuity and change. Current opinion in neurology [Internet]. 2019;32(3):327–37. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30985371
  17. Schwenkenbecher P, Wurster U, Konen FF, Gingele S, Sühs KW, Wattjes MP, et al. Impact of the McDonald Criteria 2017 on Early Diagnosis of Relapsing-Remitting Multiple Sclerosis. Frontiers in Neurology [Internet]. 2019 Mar 15 [cited 2020 Apr 30];10. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6428717/
  18. Vidal-Jordana A, Rovira A, Calderon W, Arrambide G, Joaquín Castilló, Moncho D, et al. Adding the Optic Nerve in Multiple Sclerosis Diagnostic Criteria. Neurology. 2024 Jan 9;102(1). Available from: https://pubmed.ncbi.nlm.nih.gov/37688999/
  19. Rae-Grant A, Day GS, Marrie RA, Rabinstein A, Cree BAC, Gronseth GS, et al. Comprehensive systematic review summary: Disease-modifying therapies for adults with multiple sclerosis. Neurology. 2018 Apr 23;90(17):789–800. Available from: https://pubmed.ncbi.nlm.nih.gov/29686117/
  20. Saguil A, Farnell Iv EA, Jordan TS. Multiple Sclerosis: A Primary Care Perspective. American Family Physician [Internet]. 2022 Aug 1;106(2):173–83. Available from: https://pubmed.ncbi.nlm.nih.gov/35977131/
  21. Haki M, AL-Biati HA, Al-Tameemi ZS, Ali IS, Al-hussaniy HA. Review of multiple sclerosis: Epidemiology, etiology, pathophysiology, and treatment. Medicine [Internet]. 2024 Feb 23;103(8):e37297–7. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10883637/
  22. Óscar Fernández, Per Soelberg Sörensen, Comi G, Vermersch P, Hartung HP, Letizia Leocani, et al. Managing multiple sclerosis in individuals aged 55 and above: a comprehensive review. Frontiers in immunology [Internet]. 2024 Apr 5;15. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11032020/
  23. Fitzgerald KC, Tyry T, Salter A, Cofield SS, Cutter G, Fox R, et al. Diet quality is associated with disability and symptom severity in multiple sclerosis. Neurology [Internet]. 2017 Dec 6;90(1):e1–11. Available from: https://n.neurology.org/content/90/1/e1
  24. Alhomoud MA, Khan AS, Alhomoud I. The Potential Preventive Effect of Pregnancy and Breastfeeding on Multiple Sclerosis. European Neurology. 2021;84(2):71–84. Available from: https://pubmed.ncbi.nlm.nih.gov/33744881/
  25. Schubert C, Steinberg L, Peper J, Ramien C, Hellwig K, Köpke S, et al. Postpartum relapse risk in multiple sclerosis: a systematic review and meta-analysis. Journal of Neurology, Neurosurgery, and Psychiatry [Internet]. 2023 Feb 20;jnnp–2022-330533. Available from: https://pubmed.ncbi.nlm.nih.gov/36807056/
  26. Hardy D, Chitnis T, Waubant E, Banwell B. Preventing Multiple Sclerosis: The Pediatric Perspective. Frontiers in Neurology. 2022 F
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Gauri Adhikaria, Aakriti Karkib

a Department of Internal Medicine, Washington University/Consortium at Missouri Baptist Medical Center, St. Louis, MO, USA

b Jalalabad Ragib Rabeya Medical College and Hospital, Sylhet, Bangladesh

Submitted on 03/13/2025

Last Submitted

Background

Multiple Sclerosis (MS) is a lifelong and unpredictable condition that affects the brain, spinal cord, and optic nerves. Because the central nervous system controls everything the body does, MS is considered one of the most common disabling neurological diseases. It most often begins between the ages of 20 and 30, and women are about four times more likely to develop it than men. [1]

In MS, the immune system mistakenly attacks myelin, the protective, fatty covering surrounding nerve fibers in the central nervous system. When this myelin is damaged, it leaves behind scar tissue, called sclerosis or plaques. Without this protective layer, nerve signals can't travel properly to and from the brain, causing a wide range of symptoms that can be both unpredictable and difficult to manage. [2]

Causes and Risk Factors of Multiple Sclerosis

The specific cause of MS remains unclear. However, various factors play a role in its development.

Figure 1.

  • Genetic Factors: While MS is not typically inherited, if someone in your family, like a parent, brother, or sister, has MS, your chances of getting it are higher. It doesn’t mean you’ll definitely get it, but you might have some genes that make you more likely to develop MS if something triggers it. [3]
  • Viral Infection: MS itself is not contagious. However, certain viral infections are believed to trigger or exacerbate MS activity in the body. The Epstein-Barr Virus (EBV), the cause of infectious mononucleosis, is the virus most commonly associated with MS. A high percentage of people with MS show evidence of past EBV infection, showing a possible link between the virus and an increased risk of developing the condition. [4]
  • Vitamin D: Lower vitamin D levels have been observed in association with MS. There's a geographical pattern to this, too. For example, people who grow up in places far from the equator (like Northern Europe or Canada) are more likely to get MS. This could be because of less sunlight and lower vitamin D. [5]
  • Smoking: Smoking is linked to both an increased risk of developing MS and a faster progression of the disease. Cessation of smoking, whether before or after an MS diagnosis, may help to slow disease progression and the associated disability. [6]
  • Teenage Obesity: Obesity during childhood or adolescence, particularly in girls, has been associated with a higher risk of developing MS. Also, in individuals already diagnosed with MS, obesity may increase the likelihood of relapses or the formation of more plaques. [7]

Types of Multiple Sclerosis

MS is an unpredictable disease. There are mainly four types of MS.

  • Relapsing-Remitting MS (RRMS): RRMS is the most common type of MS. It means a person sometimes gets symptoms like tiredness or vision problems. This is called a relapse. After that, they feel better for a while. This is called remission. These ups and downs can happen weeks, months, or even years apart. [4]
  • Secondary Progressive MS (SPMS): SPMS usually happens after someone has had Relapsing-Remitting MS (RRMS) for a while. Over time, their symptoms slowly get worse. They might still have minor relapses or feel a bit better sometimes, but the disease keeps getting worse. Without treatment, many people with strong RRMS may later get SPMS. [8]
  • Primary Progressive MS (PPMS): PPMS is a less common type of MS. From the start, symptoms slowly get worse over time. There are no clear relapses or times when the person feels much better. The disability slowly builds up. [9]
  • Progressive Relapsing MS (PRMS): PRMS is the rarest type of MS. From the beginning, symptoms keep getting worse. The person also has sudden relapses. They might feel a bit better after a relapse, but the disease still gets worse over time. [10]

Symptoms of Multiple Sclerosis

The symptoms of MS are highly variable in severity, duration, and how they manifest. No two people with MS experience the same set of symptoms, and an individual's symptoms can change or fluctuate over time. Common symptoms include:

Figure 2.

  • Visual Problems: Visual problems are often one of the first signs of MS. You might have blurry vision or trouble telling colors apart, like red and green. Your eye might hurt, especially when you move it. This can happen because of swelling in the nerve that connects your eye to your brain, called the optic nerve. [11]
  • Fatigue: Fatigue is a major symptom for about 80% of people with MS. It can make you feel extremely tired and weak, even if you haven't done anything physically tiring. This fatigue can make it hard to go about your daily activities. [12]
  • Pain: Pain in MS can show up in two main ways. The first is neuropathic pain that feels like sharp, stabbing pain, especially in the face, burning, tingling, or squeezing in the arms, legs, or torso. The second one is musculoskeletal pain, including back, neck, or joint pain. Some people also feel a tight, squeezing sensation around their torso, called the "MS hug." [12]
  • Walking Difficulties: These are very common in MS. They can happen because of muscle weakness, making it hard to lift your legs or walk. Balance problems can cause unsteadiness, and sensory issues like numbness or tingling can make walking harder. [12]
  • Spasticity: Spasticity in MS means muscle stiffness and uncontrollable muscle contractions, which make it harder to move. It can range from mild tightness to strong, painful spasms, especially in the legs. [12]
  • Cognitive Changes: People with MS might have trouble thinking clearly. This can make it hard to find the right words, remember things like tasks at work or home, or make decisions. They might also struggle to understand information during conversations or activities. These issues can make work, school, and socializing harder. It’s like their brain takes a little longer to process everything. [13]
  • Bowel and Bladder Problems: Many people have constipation or trouble controlling their bowel movements. For the bladder, issues can include needing to use the bathroom a lot at night, feeling the urge to go suddenly, having to go more often during the day, or even leaking urine or having accidents. [14]
  • Emotional Changes: Emotional changes are common in MS. Many people feel depressed, which can be caused by the disease itself or the stress of living with it. Anxiety is also common because MS can be unpredictable. Some people also have sudden mood swings, like crying, laughing, or getting angry for no clear reason. [15]

Diagnosis of Multiple Sclerosis

The diagnosis of MS involves looking at several things. The most important one is ruling out other neurological conditions. Sometimes, the tests are done to rule out conditions other than diagnosing MS.

Figure 3.

  • Medical History: A detailed medical history is very important when diagnosing MS. Doctors look for a history of at least two separate episodes of neurological symptoms, like weakness or vision problems, that happened at different times (usually at least one month apart). Each episode should last at least 24 hours. These symptoms must show damage to the myelin in more than one brain or spinal cord area and can’t be explained by another disease. [3]
  • Magnetic Resonance Imaging (MRI): An MRI is a special machine that uses magnets and radio waves to take clear pictures of your brain and spine. You lie down inside a big tube, and the machine makes images of your brain and spine from different angles. These pictures help doctors see if there’s any damage, like inflammation, demyelination (damage to the protective layer around your nerves), or lesions (plaques), which are signs of MS. MRIs are important for diagnosing MS and for checking how the disease is changing over time. The test usually takes about 30 to 60 minutes and is painless. [16]
  • Lumbar Puncture (Spinal Tap): A lumbar puncture is a test where a doctor takes a small sample of the fluid around your spine, called cerebrospinal fluid (CSF). This fluid helps protect your brain and spinal cord. In people with MS, the CSF can show signs of problems, like high levels of oligoclonal bands (special proteins that show there’s inflammation in the brain or spinal cord) or more immune cells than normal. [17]
  • Evoked Potentials (EP): These tests measure how your brain reacts to specific stimuli, like lights, sounds, or touch. Different types, such as visual evoked potentials (VEP), check your vision pathways with flashing lights or patterns. Somatosensory Evoked Potentials (SSEP) use small electrical shocks to test how your brain responds to touch, temperature, and pain. Auditory Evoked Potentials (AEP) check your hearing pathways with sounds or clicks. Electrodes are placed on your scalp to record your brain's responses. If the signals are slow or unusual, it could mean nerve damage, which happens in MS. [18]
  • Blood Tests: Blood tests can’t diagnose MS directly, but they help doctors rule out other conditions with similar symptoms. These tests can check for problems like lupus, Sjogren's syndrome, vitamin or mineral deficiencies, certain infections, and rare genetic disorders. [18]

Treatment of Multiple Sclerosis

While there is currently no cure for MS, various treatments are available to help manage the condition and alleviate symptoms. The specific treatment approach depends on the type and stage of MS, as well as the individual's specific symptoms.

Figure 4.

  • Disease-Modifying Therapies (DMTs): These medications are used to treat relapsing forms of MS. These medicines help by making the relapses (when symptoms get worse) happen less often and not as severely. They also slow down the disease and reduce brain and spinal cord inflammation. Some examples of DMTs that the American Academy of Neurology reviews are interferons, glatiramer acetate, dimethyl fumarate, fingolimod, and newer medicines like ocrelizumab and siponimod. These treatments can help people with MS feel better and keep the disease from getting worse. [19]
  • Treatment of Acute Relapses: When someone with MS has a relapse, doctors may give corticosteroids to help reduce inflammation and help them recover faster. If the relapse is very severe and doesn't improve with steroids, doctors might suggest a treatment called plasma exchange (plasmapheresis). This procedure helps by removing some of the harmful substances from the blood that might be making the relapse worse. [20]
  • Physical and Occupational Therapy: They are essential for managing MS. Physical therapy helps people with MS stay active, improve their balance, coordination, and strengthen their muscles. Occupational therapists help by teaching ways to make daily activities easier, using special tools or techniques to help people stay independent in dressing, cooking, or bathing. These therapies help people with MS live a better and more independent life. [21]
  • Lifestyle Modifications: Eating a healthy diet with balanced nutrients is important, staying active with regular exercise as much as possible, and avoiding smoking is important. Also, stress management techniques, like relaxation exercises or deep breathing, can help reduce stress and improve overall health. These changes can make a big difference in how MS is managed daily. [20]
  • Monitoring and Follow-Up: This is an integral part of the treatment. Your doctor will track how the disease is progressing, how well the treatment is working, and if there are any side effects from the medications. Based on their findings, your doctor will adjust your treatment plan to ensure it best fits your needs. This helps make sure your treatment stays as effective as possible. [22]

Multiple Sclerosis and Diet

Nutrition plays a vital role in managing MS and supporting your overall well-being. There is no specific diet called the "MS diet," but eating a balanced and nutritious diet can be helpful. Studies have shown that a diet with whole foods, including a mix of vegetables, fruits, beans, whole grains, seeds, and nuts, is related with lower disability and symptom severity in people with MS. These foods are packed with vitamins, minerals, antioxidants, and fiber, all of which support your body.

Omega-3 fatty acids, which are found in fatty fish like salmon and sardines, as well as flaxseeds and walnuts, have anti-inflammatory effects that might help with MS. It's also important to drink enough water, as staying hydrated can help manage symptoms like fatigue and constipation.

Some people with MS also benefit from vitamin D supplements, especially if their vitamin D levels are low. However, you should always talk to your doctor before starting any new supplements to ensure it’s the right choice. [23]

Multiple Sclerosis and Pregnancy

Pregnancy in women with MS requires some special attention. Most of the time, pregnancy doesn’t increase the risk of MS relapses, especially during the second and third trimesters when the immune system naturally becomes less active. Many women with MS notice that their symptoms ease up during pregnancy. However, there’s a small chance of having a relapse in the first few months after giving birth. [24]

Women with MS need to work closely with their doctor during pregnancy. Some MS treatments may need to be adjusted or stopped temporarily to ensure both the mother and baby stay healthy. With the right planning and care, most women with MS can have a healthy pregnancy and deliver a healthy baby. [25]

Living with Multiple Sclerosis

Living with MS can be tough, but there are ways to manage it effectively. Following your doctor’s instructions for medications is really important. As mobility problems arise, tools like canes or walkers can help you stay independent, and rehabilitation activities can keep or improve your physical abilities. You can also make your home safer by adding things like grab bars or rearranging furniture to make moving around easier. It's important to talk openly with your family and doctor about your needs to build a strong support system. By taking these steps, you can handle the challenges of MS with more strength and confidence. [19]

Can Multiple Sclerosis be prevented?

Right now, there’s no known way to prevent MS. We don’t fully understand how or why it develops, so it’s not something we can predict or stop just yet. However, researchers are working hard to figure out what causes MS and find out if there are things that can reduce the risk. Some studies suggest that healthy lifestyle choices, like getting enough vitamin D, quitting smoking, and eating a balanced diet with regular exercise, can improve overall health and might help lower the risk of other long-term health problems. But, for now, there's no guaranteed way to stop MS from happening, especially if someone is already at risk. [26]

Questions To Ask Your Doctor

  1. How can I have more energy and reduce tiredness during the day?
  2. What signs mean my MS is getting worse, and when should I see a doctor?
  3. Is it safe to exercise with MS, and what exercises should I do?
  4. Are there any support groups or resources to help me deal with MS?
  5. Are there any clinical trials I can join to help with my MS?

Conflict of Interest

GA is a paid research assistant at ehealthyinfo. AK is a non-paid research assistant at ehealthyinfo. AJPHI is an official publication of ehealthyinfo. No other conflict of interest declared.

Peer Reviewed By

Dr. Sumit Saurav Karna​​, MD

Charleston Area Medical Center, WV, USA

References

  1. Zainab SR, Khan JZ, Tipu MK, Jahan F, Irshad N. Decoding multiple sclerosis: Unravelling the complexities of pathogenesis, progression, mechanisms and therapeutic innovations. Neuroscience [Internet]. 2024;S0306-4522(24)007358. Available from: https://pubmed.ncbi.nlm.nih.gov/39709058/
  2. Faissner, S., Plemel, J.R., Gold, R. and Yong, V.W. (2019). Progressive multiple sclerosis: from pathophysiology to therapeutic strategies. Nature Reviews Drug Discovery, [online] 18(12). Available from: https://pubmed.ncbi.nlm.nih.gov/31399729/
  3. McGinley MP, Goldschmidt CH, Rae-Grant AD. Diagnosis and Treatment of Multiple Sclerosis. JAMA [Internet]. 2021 Feb 23;325(8):765–79. Available from: https://jamanetwork.com/journals/jama/article-abstract/2776694
  4. McKay KA, Kwan V, Duggan T, Tremlett H. Risk Factors Associated with the Onset of Relapsing-Remitting and Primary Progressive Multiple Sclerosis: A Systematic Review. BioMed Research International [Internet]. 2015;2015:1–11. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4329850/
  5. Olsson T, Barcellos LF, Alfredsson L. Interactions between genetic, lifestyle and environmental risk factors for multiple sclerosis. Nature Reviews Neurology. 2016 Dec 9;13(1):25–36. Available from:https://pubmed.ncbi.nlm.nih.gov/27934854/
  6. Hedström AK, Hillert J, Olsson T, Alfredsson L. Factors affecting the risk of relapsing-onset and progressive-onset multiple sclerosis. Journal of Neurology, Neurosurgery & Psychiatry [Internet]. 2021 Oct 1 [cited 2022 Oct 3];92(10):1096–102. Available from: https://jnnp.bmj.com/content/92/10/1096
  7. Alfredsson L, Olsson T. Lifestyle and Environmental Factors in Multiple Sclerosis. Cold Spring Harbor Perspectives in Medicine [Internet]. 2018 May 7;9(4):a028944. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6444694/
  8. Cree BAC, Arnold DL, Chataway J, Chitnis T, Fox RJ, Pozo Ramajo A, et al. Secondary Progressive Multiple Sclerosis. Neurology [Internet]. 2021 Jun 4;97(8):378–88. Available from: https://n.neurology.org/content/97/8/378
  9. Antel J, Antel S, Caramanos Z, Arnold DL, Kuhlmann T. Primary progressive multiple sclerosis: part of the MS disease spectrum or separate disease entity? Acta Neuropathologica. 2012 Feb 11;123(5):627–38. Available from: https://pubmed.ncbi.nlm.nih.gov/22327362/
  10. Confavreux C, Vukusic S. Natural history of multiple sclerosis: a unifying concept. Brain [Internet]. 2006 Jan 16;129(3):606–16. Available from: https://academic.oup.com/brain/article/129/3/606/390915
  11. Kraker JA, Xu SC, Flanagan EP, Foster R, Wang F, Chen JJ. Ocular Manifestations of Multiple Sclerosis: A Population-Based Study. Journal of neuro-ophthalmology : the official journal of the North American Neuro-Ophthalmology Society [Internet]. 2024 Jan;44(2):157–61. Available from: https://pubmed.ncbi.nlm.nih.gov/38457238/
  12. Ford H. Clinical presentation and diagnosis of multiple sclerosis. Clinical Medicine [Internet]. 2020 Jul;20(4):380–3. Available from: https://pubmed.ncbi.nlm.nih.gov/32675142/
  13. Dejan Jakimovski, Weinstock-Guttman B, Roy S, Jaworski M, Hancock LM, Nizinski A, et al. Cognitive Profiles of Aging in Multiple Sclerosis. Frontiers in Aging Neuroscience. 2019 May 10;11. Available from: https://pubmed.ncbi.nlm.nih.gov/31133845/
  14. Miller D, Barkhof F, Montalban X, Thompson A, Filippi M. Clinically isolated syndromes suggestive of multiple sclerosis, part I: natural history, pathogenesis, diagnosis, and prognosis. The Lancet Neurology. 2005 May;4(5):281–8. Available from: https://pubmed.ncbi.nlm.nih.gov/15847841/
  15. Rimkus C de M, Nucci MP, Avolio IB, Apóstolos-Pereira SL, Callegaro D, Wagner MB, et al. Atrophy Patterns in Patients With Multiple Sclerosis With Cognitive Impairment, Fatigue, and Mood Disorders. Neurology [Internet]. 2024 Winter;103(12):e210080. Available from: https://pubmed.ncbi.nlm.nih.gov/39571119/
  16. Hartung HP, Graf J, Aktas O, Mares J, Barnett MH. Diagnosis of multiple sclerosis: revisions of the McDonald criteria 2017 - continuity and change. Current opinion in neurology [Internet]. 2019;32(3):327–37. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30985371
  17. Schwenkenbecher P, Wurster U, Konen FF, Gingele S, Sühs KW, Wattjes MP, et al. Impact of the McDonald Criteria 2017 on Early Diagnosis of Relapsing-Remitting Multiple Sclerosis. Frontiers in Neurology [Internet]. 2019 Mar 15 [cited 2020 Apr 30];10. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6428717/
  18. Vidal-Jordana A, Rovira A, Calderon W, Arrambide G, Joaquín Castilló, Moncho D, et al. Adding the Optic Nerve in Multiple Sclerosis Diagnostic Criteria. Neurology. 2024 Jan 9;102(1). Available from: https://pubmed.ncbi.nlm.nih.gov/37688999/
  19. Rae-Grant A, Day GS, Marrie RA, Rabinstein A, Cree BAC, Gronseth GS, et al. Comprehensive systematic review summary: Disease-modifying therapies for adults with multiple sclerosis. Neurology. 2018 Apr 23;90(17):789–800. Available from: https://pubmed.ncbi.nlm.nih.gov/29686117/
  20. Saguil A, Farnell Iv EA, Jordan TS. Multiple Sclerosis: A Primary Care Perspective. American Family Physician [Internet]. 2022 Aug 1;106(2):173–83. Available from: https://pubmed.ncbi.nlm.nih.gov/35977131/
  21. Haki M, AL-Biati HA, Al-Tameemi ZS, Ali IS, Al-hussaniy HA. Review of multiple sclerosis: Epidemiology, etiology, pathophysiology, and treatment. Medicine [Internet]. 2024 Feb 23;103(8):e37297–7. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10883637/
  22. Óscar Fernández, Per Soelberg Sörensen, Comi G, Vermersch P, Hartung HP, Letizia Leocani, et al. Managing multiple sclerosis in individuals aged 55 and above: a comprehensive review. Frontiers in immunology [Internet]. 2024 Apr 5;15. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11032020/
  23. Fitzgerald KC, Tyry T, Salter A, Cofield SS, Cutter G, Fox R, et al. Diet quality is associated with disability and symptom severity in multiple sclerosis. Neurology [Internet]. 2017 Dec 6;90(1):e1–11. Available from: https://n.neurology.org/content/90/1/e1
  24. Alhomoud MA, Khan AS, Alhomoud I. The Potential Preventive Effect of Pregnancy and Breastfeeding on Multiple Sclerosis. European Neurology. 2021;84(2):71–84. Available from: https://pubmed.ncbi.nlm.nih.gov/33744881/
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