| Motor & mobility |
| Spasticity |
- Baclofen (start 5 mg TID, titrate)
- Tizanidine; gabapentin; benzodiazepines
- Botulinum toxin — focal spasticity
- Intrathecal baclofen pump — severe
|
- Don’t abolish useful extensor tone (aids standing)
- ⚠ Avoid abrupt baclofen withdrawal
- Tizanidine: sedation, hypotension, check LFTs
- Pair with stretching / PT
|
| Gait / walking speed |
- Dalfampridine (Ampyra) 10 mg PO BID
- Physical therapy, gait aids
|
- K⁺-channel blocker — improves walking speed in ~1/3
- ⚠ Contraindicated: seizure history, CrCl ≤50
- Don’t crush the ER tablet
|
| Tremor |
- Clonazepam, propranolol, primidone, topiramate
- Thalamic DBS — refractory
|
- Often the hardest MS symptom to treat
- OT strategies, wrist weights
|
| Fatigue & sleep |
| Fatigue |
- Amantadine 100 mg BID
- Modafinil / armodafinil
- Methylphenidate
- Exercise & sleep hygiene
|
- First exclude depression, sleep disorder, thyroid, anemia, deconditioning, sedating meds
- Trial evidence modest — amantadine/modafinil/methylphenidate no better than placebo (TRIUMPHANT-MS)
- Avoid late-day stimulants
|
| Mood, affect & cognition |
| Depression / anxiety |
- SSRIs (sertraline, escitalopram)
- SNRIs (duloxetine, venlafaxine)
- Psychotherapy / CBT
|
- ⚠ Depression & suicide risk are elevated in MS — screen actively
- Interferon-β labels warn of depression / suicidal ideation — monitor mood
- Duloxetine / venlafaxine also help neuropathic pain
|
| Pseudobulbar affect |
- Dextromethorphan / quinidine (Nuedexta)
- SSRIs or TCAs (off-label)
|
- Involuntary laughing/crying incongruent with mood — distinguish from depression
- Quinidine: QT prolongation, CYP2D6 interactions
|
| Cognitive impairment |
- Cognitive rehabilitation
- Treat fatigue, mood, sleep
|
- No pharmacotherapy proven (donepezil negative)
- Optimize DMT, fatigue, depression, and sleep first
|
| Sensory & paroxysmal |
| Neuropathic pain / dysesthesia |
- Gabapentin, pregabalin
- Duloxetine, amitriptyline
|
- Central pain & painful tonic spasms are common
- TCAs: anticholinergic load (worsens bladder retention, cognition) — use cautiously
|
| Trigeminal neuralgia / paroxysmal symptoms |
- Carbamazepine, oxcarbazepine
- Acetazolamide, lamotrigine, gabapentin (tonic spasms)
|
- MS is a key secondary cause — suspect in young/bilateral cases, get MRI
- Monitor Na⁺ (hyponatremia) & CBC on carbamazepine/oxcarbazepine
- Microvascular decompression / rhizotomy if refractory
|
| Heat sensitivity (Uhthoff) |
- Cooling (garments, pre-cooling)
- Avoid heat / fever
|
- Transient pseudo-relapse from raised body temperature — not a true relapse
- Don’t treat with steroids; treat fever / infection
|
| Bladder, bowel & sexual |
| Bladder — urgency / overactivity |
- Antimuscarinics (oxybutynin, solifenacin, tolterodine)
- Mirabegron (β3-agonist)
- Intradetrusor onabotulinumtoxinA
|
- ⚠ Check post-void residual first — anticholinergics worsen incomplete emptying
- Antimuscarinics add anticholinergic / cognitive burden; mirabegron avoids it
- Treat UTIs
|
| Bladder — incomplete emptying / DSD |
- Clean intermittent catheterization
- Treat / monitor for UTI
|
- Detrusor–sphincter dyssynergia → high residuals, recurrent UTIs, reflux
- Urology / urodynamics for mixed patterns
|
| Bowel (constipation) |
- Fluids, fiber
- Scheduled bowel program, laxatives
|
- Very common; address before it worsens bladder & spasticity
|
| Sexual dysfunction |
- PDE5 inhibitors (sildenafil, tadalafil) for erectile dysfunction
- Lubricants, pelvic-floor therapy, counseling
|
- Often multifactorial — also treat fatigue, spasticity, mood, offending meds (SSRIs)
- ⚠ PDE5 inhibitors contraindicated with nitrates
|
