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Multiple sclerosis in adults: management

  • This Guidelines summary includes recommendations that are relevant to the primary care setting. Please refer to the full guideline for the complete set of recommendations

Diagnosing MS

  • Be aware that clinical presentations in multiple sclerosis (MS) include:
    • loss or reduction of vision in one eye with painful eye movements
    • double vision
    • ascending sensory disturbance and/or weakness
    • problems with balance, unsteadiness or clumsiness
    • altered sensation travelling down the back and sometimes into the limbs when bending the neck forwards (Lhermitte's symptom)
  • Be aware that usually people with MS present with neurological symptoms or signs as described above, and:
    • are often aged under 50 and
    • may have a history of previous neurological symptoms and
    • have symptoms that have evolved over more than 24 hours and
    • have symptoms that may persist over several days or weeks and then improve
  • Do not routinely suspect MS if a person's main symptoms are fatigue, depression or dizziness unless they have a history or evidence of focal neurological symptoms or signs
  • Before referring a person suspected of having MS to a neurologist, exclude alternative diagnoses by performing blood tests including:
    • full blood count
    • inflammatory markers for example erythrocyte sedimentation rate, C-reactive protein
    • liver function tests
    • renal function tests
    • calcium
    • glucose
    • thyroid function tests
    • vitamin B12
    • HIV serology
  • Do not diagnose MS on the basis of MRI findings alone
  • Refer people suspected of having MS to a consultant neurologist. Speak to the consultant neurologist if you think a person needs to be seen urgently
  • Only a consultant neurologist should make the diagnosis of MS on the basis of established up-to-date criteria, such as the revised 2010 McDonald criteria,* after:
    • assessing that episodes are consistent with an inflammatory process
    • excluding alternative diagnoses
    • establishing that lesions have developed at different times and are in different anatomical locations for a diagnosis of relapsing-remitting MS
    • establishing progressive neurological deterioration over 1 year or more for a diagnosis of primary progressive MS
  • If a person is suspected* of having MS but does not fulfil the diagnostic criteria, plan a review. Discuss the timing of the review with the person and ensure they know who to contact for advice if they develop further neurological symptoms or if current symptoms worsen
  • Offer people suspected of having MS, information about support groups and national charities

Optic neuritis and neuromyelitis optica

  • If a person has an episode of isolated optic neuritis, confirmed by an ophthalmologist, refer them to a consultant neurologist for further assessment
  • Diagnosis of neuromyelitis optica should be made by an appropriate specialist based on established up-to-date criteria

Providing information and support

  • NICE has produced guidance on the components of good patient experience in adult NHS services. This includes recommendations on communication, information and coordination of care. Follow the recommendations in Patient experience in adult NHS services (NICE clinical guideline 138)

Information at the time of diagnosis

  • The consultant neurologist should ensure that people with MS and, with their agreement their family members or carers, are offered oral and written information at the time of diagnosis. This should include, but not be limited to, information about:
    • what MS is
    • treatments, including disease-modifying therapies
    • symptom management
    • how support groups, local services, social services and national charities are organised and how to get in touch with them
    • legal requirements such as notifying the Driver and Vehicle Licensing Agency (DVLA) and legal rights including social care, employment rights and benefits
  • Discuss with the person with MS and their family members or carers whether they have social care needs and if so refer them to social services for assessment. Ensure the needs of children of people with MS are addressed
  • Offer the person with MS a face-to-face follow-up appointment with a healthcare professional with expertise in MS to take place within 6 weeks of diagnosis

Ongoing information and support

  • Review information, support and social care needs regularly. Continue to offer information and support to people with MS or their family members or carers even if this has been declined previously
  • Ensure people with MS and their family members or carers have a management plan that includes who to contact if their symptoms change significantly
  • Explain to people with MS that the possible causes of symptom changes include:
    • another illness such as an infection
    • further relapse
    • change of disease status (for example progression)
  • Talk to people with MS and their family members or carers about the possibility that the condition might lead to cognitive problems
  • When appropriate, explain to the person with MS (and their family members or carers if the person wishes) about advance care planning and power of attorney

Coordination of care

  • Care for people with MS using a coordinated multidisciplinary approach. Involve professionals who can best meet the needs of the person with MS and who have expertise in managing MS including:
    • consultant neurologists
    • MS nurses
    • physiotherapists and occupational therapists
    • speech and language therapists, psychologists, dietitians, social care and continence specialists
    • GPs
  • Offer the person with MS an appropriate single point of contact to coordinate care and help them access services

Modifiable risk factors for relapse or progression of MS


  • Encourage people with MS to exercise. Advise them that regular exercise may have beneficial effects on their MS and does not have any harmful effects on their MS


  • Be aware that live vaccinations may be contraindicated in people with MS who are being treated with disease-modifying therapies
  • Discuss with the person with MS:
    • the possible benefits of flu vaccination and
    • the possible risk of relapse after flu vaccination if they have relapsing-remitting MS
  • Offer flu vaccinations to people with MS in accordance with national guidelines, which recommend an individualised approach according to the person's needs


  • Explain to women of childbearing age with MS that:
    • relapse rates may reduce during pregnancy and may increase 3–6 months after childbirth before returning to pre-pregnancy rates
    • pregnancy does not increase the risk of progression of disease
  • If a person with MS is thinking about pregnancy, give them the opportunity to talk with a healthcare professional with knowledge of MS about:
    • fertility
    • the risk of the child developing MS
    • use of vitamin D before conception and during pregnancy
    • medication use in pregnancy
    • pain relief during delivery (including epidurals)
    • care of the child
    • breastfeeding


  • Advise people with MS not to smoke and explain that it may increase the progression of disability. (See Smoking cessation services NICE public health guideline 10.)

*Polman CH, Reingold SC, Banwell B et al. (2011) Diagnostic criteria for multiple sclerosis: 2010 revisions to the McDonald criteria. Annals of Neurology 69: 292–302.
†'Chronic neurological disease: conditions in which respiratory function may be compromised, due to neurological disease (e.g. polio syndrome sufferers). Clinicians should consider on an individual basis the clinical needs of patients including individuals with cerebral palsy, multiple sclerosis and related or other similar conditions; or hereditary and degenerative disease of the nervous system of muscles; or severe disability.' (Department of Health 2013).

full guideline available from…
National Institute for Health and Care Excellence, Level 1A, City Tower, Piccadilly Plaza, Manchester, M1 4BT
National Institute for Health and Care Excellence.Multiple sclerosis in adults: management. October 2014.
First included: February 2004.