Let's Talk About Multiple Sclerosis Signs and Symptoms
MS symptoms can range from the totally obvious to the easily dismissed. We help you figure out what to look for.
Ask 10 people with multiple sclerosis (MS) what their symptoms are, and you’ll likely get 10 different answers. While there are common challenges—eye problems, fatigue, trouble with gait and memory—exactly how and when you experience them will vary. Which means you might not know what to expect if you’ve recently been diagnosed with this autoimmune condition, and you could really have no clue what's happening if you haven't been diagnosed yet. The good news? We’re here to help. We’ll explain the range of possible MS symptoms that can warrant a trip to the doctor's (and give you a head's up on what might happen during a disease flare). And know this: Right now, you have more control over MS than ever before due to powerfully effective new treatments, plus a greater—and growing!—understanding of how to keep those symptoms at bay.
Our Pro Panel
We went to some of the nation's top MS experts to bring you the most scientific and up-to-date information possible.
Meghan Beier, Ph.D.
Assistant Professor of Physical Medicine and Rehabilitation and Clinical Neuropsychologist
Johns Hopkins Medicine Multiple Sclerosis Center
Bruce Cohen, M.D.
Chief of MS/Neuroimmunology, Department of Neurology
Northwestern University Feinberg School of Medicine
Neeta Garg, M.D.
Associate Professor of Clinical Neurology
University of Miami Miller School of Medicine
People with MS report a range of symptoms including eye pain and vision loss (known as optic neuritis), as well as cognitive issues, problems with walking and balance, chronic fatigue, spasticity, bladder and bowel problems, and depression, too.
Possibly both. Some studies link the chronic inflammation that comes with autoimmune disorders with increased risk for depression. Then again, you might feel overwhelmed dealing with a lifelong condition like MS, and the fatigue that comes with it only exacerbates the problem. If you’re feeling depressed, don’t hesitate: Tell your doctor, and ask for help.
A few decades ago, almost everyone with RRMS went on to develop a more progressive form of the disease within 10 years of being diagnosed. Now, with advances in MS therapies called disease-modifying treatments (DMTs), typical symptoms might not progress for decades—or even at all.
While you might face new challenges in the bedroom, like sustaining an erection (men) or reduced clitoral sensation (women), speak with your doctor about getting your sex life back on track. And, remember, fertility is not directly affected if you’re trying to start a family.
Remind Me: What’s MS, Again?
Multiple sclerosis is a type of autoimmune disease, which means that for unknown reasons the body’s immune system mistakenly attacks healthy tissues. In MS, the target is the myelin sheath, the protective tissue that surrounds the nerves in the central nervous system (CNS), which is comprised of the brain, spinal cord, and optic nerves.
When myelin is stripped from the nerves in this way, scarring (called sclerosis) occurs. It's this damage that contributes to common MS symptoms—some of which you might be experiencing right now—including fatigue, eye pain, blurry vision, balance and gait issues, numbness, and trouble with focus and concentration.
Why? This scarring interrupts the signals traveling from the brain to the body, and sometimes even causes the loss of information altogether. As scarring builds up in the CNS—called lesion burden or lesion load—MS symptoms can progressively worsen.
What Are the Different Types of MS?
Before talking about symptoms, it’s helpful to know that there are a number of different types of MS. While people with different types of MS often share a common set of symptoms, they might experience them differently (or not experience some symptoms at all), because not all types of MS follow the same path. Here are the types:
Clinically Isolated Syndrome (CIS)
Technically, this isn’t MS—but it is a possible precursor to the disease. CIS is a special designation that describes the first flare-up of MS-like symptoms that may, or may not, be diagnosed as MS down the line.
The term CIS is used to describe a symptom attack, such as optic neuritis (pain in the eye and vision loss) or spasticity (uncontrolled contractions of the muscles, usually in the arms and legs, caused by nerve damage) and it doesn't always cause pain. If a healthcare provider suspects that the symptoms may be caused by MS, he or she will usually order an MRI and conduct other tests to rule out other diseases. To be classified as CIS, the episode must last at least 24 hours and must show demyelination (when inflammation strips away myelin from nerves in the CNS).
Relapsing-Remitting MS (RRMS)
By far the most common multiple sclerosis disease course is RRMS, comprising about 85% of all MS cases. Having RRMS means experiencing periods of symptom attacks—known as relapses, flares, or exacerbations—followed by periods of partial or total recovery, known as remissions.
The exacerbation event has to last for at least 24 hours to be considered a relapse, but it can go on for weeks or even months. It’s different for every patient and even for every relapse. How often this cycle repeats also varies for each person, but with proper treatment, many patients have months or even years between flare-ups.
Secondary-Progressive MS (SPMS)
Until two or three decades ago, most people with RRMS would go on to develop secondary-progressive MS (SPMS)—meaning, they’d never again experience periods of remission, with symptoms always present. That’s changed dramatically in recent years for many people with RRMS, thanks to effective new MS therapies called disease-modifying treatments (DMTs) that were first introduced in 1993.
Left untreated, about 50% of people with RRMS develop SPMS within 10 years. Most researchers believe that number is far lower with DMT treatments, but there haven’t been any studies to confirm this lower rate of progression. Nowadays, when people with RRMS do go on to develop secondary progressive MS, it generally takes years, if not decades, to occur. Some DMTs can even slow the progression of SPMS itself. And, for people who do develop SPMS, symptoms can be more effectively managed as well.
Primary-Progressive MS (PPMS)
If approximately 85% of people with MS start with RRMS, about 10% are affected by primary-progressive MS (PPMS). In general, people with PPMS experience few or no remissions with no symptom flare-ups—symptoms progressively worsen from the start. On rare occasions people with PPMS can go into remission.
Progressive-Relapsing MS (PRMS)
Affecting just 5% of people with MS, PRMS is the rarest form of the disease, known for its steadily worsening symptoms and acute (severe) relapses.
What Are the Symptoms of MS?
At its core, MS is a condition that harms the nerves of the central nervous system, or CNS. Damaged nerve fibers can’t transmit electrical signals efficiently, or sometimes at all, causing a wide range of physical and cognitive symptoms.
There is usually no telling what specific symptoms someone will develop when they have MS, although cognitive lapses and eye-related problems are often the first symptoms people experience. The different stages and types of MS sometimes share symptoms, although every person with MS is affected in his or own way. That said, if you have MS, here are some of the ways the disease might affect you.
Problems with cognition and thinking are good examples of “invisible” symptoms—the ones that can profoundly affect you but that no one else picks up on right away. That said, cognitive symptoms are usually what get people to make that initial appointment with their doctor. They include having difficulty with:
Retaining and processing new memories
Processing new information
Attention to detail
Executive function (a fancy way of describing the ability to plan and prioritize)
Copying or drawing shapes, figures, or lines
Verbal fluency, which your ability to find just the right word, even a familiar one
Cognitive changes are common and can occur at any time—even in the first stages of MS, although they tend to worsen as the disease progresses. Fortunately, a range of treatment options, including daily brain exercises and other strategies, can help keep your mind sharp and engaged.
Numbness and Tingling
Numbness and tingling are some of the most common symptoms of MS and are often among the first to show up. No mystery here—these symptoms are caused by the stripped myelin not allowing sensory nerves to transmit impulses back to the brain. Result? Lack of feeling.
Although some people with MS consider numbness to be a mere annoyance, you’ll need to be careful around extreme cold and heat—like when you’re cooking—and be on guard against injuries you simply can’t feel. (Like when you pick up a hot plate.) Numbness can prevent you from even noticing you’ve just burned yourself, for example.
Vision problems are often an early warning sign for MS. The optic nerves attach to the back of the eyes and send information directly to the brain. When the immune system attacks the myelin sheaths of the optic nerves, it’s called optic neuritis.
Pain behind the eye and a temporary loss of vision—usually in one eye only—are the main signs of optic neuritis. If you develop it, you’ll almost certainly know it and seek treatment, either from an eye doctor (optometrist or ophthalmologist) or a brain specialist (neurologist), ASAP. That’s because, when optic neuritis strikes, it usually causes undeniable discomfort. Here are some of the symptoms:
You’ll likely feel a constant ache or a “striking” sensation behind a single eye.
You'll probably also have noticeable vision loss in that same eye, including blurred or double vision; loss of peripheral vision; loss of color vision; dim vision (as though someone turned the lights down); or even flashing or flickering lights with eye movements.
While it’s possible to have optic neuritis and not have MS—certain infections can cause this eye condition, too—if you have optic neuritis and one or more brain lesions are also found on an MRI scan, a diagnosis of MS is likely. Even if you don’t have brain lesions during a bout of optic neuritis, experiencing a single episode of ON gives you a 50% higher risk of developing MS during your lifetime. We know that's scary to hear, but simply knowing you might have a susceptibility to this condition can help you stay on top of any new symptoms. And that, our friends, can help you get diagnosed and treated much more quickly.
The other upside: Vision loss is usually (and thankfully) temporary from optic neuritis. Symptoms tend to worsen for one to seven days, then improve over the course of one to three months. In severe cases, steroid eye drops are used to reduce inflammation of the optic nerve. Optic neuritis can be a one-time event and never return. However, in 15% to 20% of cases it strikes again.
Fatigue is a nearly universal symptom of MS. It’s thought to be at least partially connected to your body fighting inflammation, which uses up a lot of your energy. Even so, the exact cause of fatigue in people with MS is largely unknown. And it’s often misunderstood by coworkers and family members, who may think a person with MS is simply “down in the dumps” or is not trying hard enough to get out of bed to face the day. If only.
Fatigue can also occur for reasons that may not be directly related to inflammation but rather are byproducts of it. For example, a person who has mobility issues might have to work harder to climb a flight of stairs. And because it can sometimes be rough to get uninterrupted sleep thanks to frequent bathroom runs (more on this in a bit), a person is going to end up pretty pooped.
However, officially, MS-related fatigue is called lassitude. According to the National MS Society, this kind of severe fatigue:
Tends to occur on a daily basis
May happen in the morning, even after a good night’s sleep
Gets worse as the day progresses
Is often aggravated by heat and humidity
Comes on suddenly
Interferes with daily responsibilities
MS-related fatigue may, in part, be connected to depression (more on that in a moment), because of the role inflammation plays in chronic conditions like MS and other inflammatory disorders.
Spasticity and Spasms
This painful stiffening of the muscles affects between 60% and 90% of people with MS (yep, it's one of the biggies that signal the condition). There are two types:
Flexor spasticity, which occurs when the muscles that bring a limb toward your body tighten up. If your forearm flexors are impacted, your hand will curl into a claw.
Extensor spasticity is the opposite. It forces your muscles to extend a limb. In this case, your extensor muscles would prevent you from closing your fingers into a fist.
Spasms are something else—the involuntary contraction of muscles. You may experience both spasms and spasticity if you have MS, and just like every other MS symptom, they're caused by the interruption of nerve signals between your muscles and brain. Some of these electrical impulses get lost, so your muscles don’t get certain messages that help control them.
Walking and Gait Difficulties
Trouble walking and moving is another common symptom of MS. Damage to nerves that serve the leg muscles can result in weakness, painful cramping, and numbness. Damage to the auditory nerve in the brain may cause vertigo, putting the world on a spin cycle. No wonder is can be harder to get around with MS, not to mention much easier to fall down. In fact, people with MS tumble three times as often as people without MS.
Weakness All Over
Weakness is common if you have MS, and it can stem from a number of sources. For starters, loss of myelin on the nerves that serve your body’s muscles may make those muscles work less efficiently, leaving you with a weakened feeling all over. In addition, the snowball effect of deconditioning may be at play: You’re weak so you don’t exercise, and you don’t exercise, so you grow weaker. It can be a bit of a vicious circle.
Clinical depression is never just the blues, and people who battle it can’t just get over it. Depression affects people with MS at higher rates than people with other chronic diseases—even terminal ones.
It’s thought that depression in MS has many causes and pathways. One aspect is the upheaval to your life that happens when you’re diagnosed with a chronic condition like MS. You may think your life is over, and wonder how you will ever live with the disease. That’s a normal and understandable reaction, and the shock is enough to cause depression in some people.
Then there is the role of inflammation. Inflammation biomarkers—chemical signals found in blood and other lab tests—can be found in people with depression. Clinically diagnosed depression also affects people with other inflammatory conditions like rheumatoid arthritis (RA) or Crohn’s disease, suggesting that inflammation may be a key factor in depression.
Finally, people who develop lesions in the right frontal lobe of the brain—which plays a role in memory formation, personality, motivation, and more—are especially likely to be associated with depression, according to some research, including a study published in Journal of Neuropsychiatry and Clinical Neuroscience.
If you have MS and feel hopeless, don’t wait—talk to your doctor. If you need help right now, call the Substance Abuse and Mental Health Services Administration (SAMHSA) hotline at 1-800-662-HELP (4357) for free, confidential, 24/7, 365-day-a-year treatment referral (in English and Spanish) for individuals and families facing mental health crises.
Pain and Itching
MS can cause pain directly and indirectly. Pain caused by damage to the nerves from MS is called neuropathic pain. It occurs when signals passing from nerve to nerve get short-circuited after they encounter an MS lesion.
Painful conditions caused by MS include:
Trigeminal neuralgia: The trigeminal nerve is the largest of the cranial nerves that give feeling to much of your face. Trigeminal neuralgia, also known as tic douloureux, happens when MS attacks this pathway, and it can be extremely painful. There are medications that can help manage it.
Lhermitte’s sign: This is an electric-shock sensation that runs down the back of the head and the spine when you bend your neck forward. It can sometimes also shoot down the arms and legs, potentially causing difficulty walking. Lhermitte’s sign is a clue that MS has damaged your cervical spine (a.k.a. your neck).
MS hug: Also known as banding or girdling, this is an uncomfortable feeling of tightness around the torso that may cause difficulty breathing and can result from muscle spasms, nerve damage, or both.
Dysesthesia: This is the term for abnormal sensations that occur because damaged nerves are sending signals incorrectly. It may manifest in the form of numbness, tingling, a burning sensation, or itching.
Tremors, Speech Problems, and Trouble Swallowing
Despite how different they may seem these symptoms often occur simultaneously. Why? Because they all relate to movement and are governed by similar parts of the brain. Tremors are involuntary movements of the limbs or head, and they're often accompanied by slurred speech and trouble swallowing (dysphagia). It’s thought that all three symptoms occur when areas of the brain known as the cerebellum and thalamus are damaged. These areas partially control movement, including movement of the mouth and throat. When they’re damaged by MS lesions, the muscles of the face, mouth, and throat don’t always work properly, which increase the risk for choking.
Bladder and Bowel Problems
Do you frequently feel like you have to “go” right this minute? This happens because MS lesions disrupt nerve signals from the brain to the bladder and bowels—and such symptoms can feel devastating because you might feel humiliated with a growing lack of control over how often, and where, you choose to relieve yourself. Four out of five people with MS have bladder problems, which can include:
Urinating more frequently
Having to go more urgently
Feeling like you’re not done urinating
Nighttime urination (nocturia)
Incontinence, or the inability to hold it in
Bowel problems can include constipation, diarrhea, or bowel incontinence.
According to one study of people with MS, 63% reported having sex less frequently after being diagnosed with this disease. Other research shows that 91% of men and 72% of women with MS surveyed reported sexual problems. Men with MS may have difficulty achieving, or sustaining, an erection; women with MS may have reduced clitoral sensation. This is likely caused by several factors, including demyelination, which affects the nerves that are associated with arousal and orgasm, as well as emotional changes and stress that come with living with a chronic condition. Basic fertility is not directly affected, although sexual problems may cause roadblocks to you or your partner becoming pregnant if you’re experiencing them.
Much like depression, sexual problems can have more than one cause when you have MS. Part of it might be how the MS lesions on your brain are affecting your nerves that control the genitals, but part may also be related to the depression and anxiety often associated with MS, the upheaval of your life after a diagnosis, chronic fatigue, or loss of quality of life.
How Can Symptoms Lead to an MS Diagnosis?
Unfortunately, no matter what your constellation of symptoms may be, there is no single, defining test for multiple sclerosis. Rather, doctors will only conclude that you have MS after systematically ruling out other diseases—including Lyme disease, HIV, lupus, brain tumors, and spine conditions, to name a few—that might be causing your symptoms. When—and only when—all signs point to MS will you get what’s called a diagnosis of exclusion or differential diagnosis.
This process can sometimes take weeks or months—remember, your doctors are being thorough, because your symptoms can be tied to so many other conditions. If you think you’re experiencing symptoms that may signal a possible MS diagnosis, talk to your healthcare practitioner. The sooner you get diagnosed with (or rule out) MS, the sooner you can begin treatment and get back to living your life.
- Prevalence of MS: Neurology. (2016). “Multiple sclerosis prevalence in the United States commercially insured population.” ncbi.nlm.nih.gov/pubmed/26888980
- Progression from RRMS to SPMS: Neurology. (2018). “The cortical damage, early relapses, and onset of the progressive phase in multiple sclerosis.” n.neurology.org/content/90/24/e2107
- MS and Depression (1): Bratisl Lek Listy. (2003). “The relation between brain MRI lesions and depressive symptoms in multiple sclerosis.” ncbi.nlm.nih.gov/pubmed/14604264
- MS and Depression (2): Journal of Neuropsychiatry and Clinical Neuroscience. (2011). “Pathogenic Mechanisms of Depression in Multiple Sclerosis.” neuro.psychiatryonline.org/doi/full/10.1176/jnp.23.3.jnp261
- MS Lesions and Healing: Journal of Neuroimaging. (2018). “Atrophied Brain Lesion Volume: A New Imaging Biomarker in Multiple Sclerosis.” onlinelibrary.wiley.com/doi/abs/10.1111/jon.12527
- MS Classification System: European Neurology. (2014). “New Multiple Sclerosis Phenotypic Classification” karger.com/Article/FullText/367614
- Depression and Inflammation: Antidepressants. (2018). “Role of Inflammation in Depression and Treatment Implications.” link.springer.com/chapter/10.1007%2F164_2018_166
- MS Symptoms (1): National Multiple Sclerosis Society. (n.d.). “MS Symptoms.” nationalmssociety.org/Symptoms-Diagnosis/MS-Symptoms
- MS Symptoms (2): Holland Hospital. (2013). “Multiple Sclerosis: Signs, Symptoms and Treatments.” youtube.com/watch?v=_Sy2ayANRPs
- MS Tremors: MS Trust. (2018). “Tremor.” mstrust.org.uk/a-z/tremor
- Early Signs of MS: Cleveland Clinic. (2018). “4 Early Warning Signs of MS You Shouldn’t Ignore.” health.clevelandclinic.org/4-early-signs-of-ms-you-shouldnt-ignore/