Ask the Doctor
Questions from our Readers
By Dr. Barry A. Hendin
MSAA’s Chief Medical Officer
Q: I am newly diagnosed. Should I begin with a moderate or higher efficacy medication?
A: A number of factors are involved in choosing your first MS medication. For primary-progressive MS, only one medication, Ocrevus® (ocrelizumab), is approved for this form of MS. For relapsing forms of MS, more than 25 disease-modifying therapies are approved for these types of MS. The best choice generally becomes clearer after a thoughtful discussion with your neurologist, based on shared decision-making.
In general, I prefer initiating therapy with a high-efficacy disease-modifying therapy, based on increasing evidence regarding the favorable benefit/risk ratio of the high-efficacy medications. However, unique circumstances, such as pregnancy, comorbidities (other existing health issues), and lifestyle choices may result in different decisions.
MSAA has created the Ultimate MS Treatment Guide, a very useful online tool for navigating the current multiple sclerosis therapies. The guide may be accessed at MStreatmentguide.org and will help address many of the questions that you might have regarding therapies.
Q: What sensory issues occur with MS and how are they treated?
A: Sensory symptoms in MS are quite variable and can affect any part of the body. Some are more specific, including trigeminal neuralgia (a shock-like pain on one side of the face), the MS hug (typically a strong and sometimes painful squeezing around the torso), or Lhermitte’s sign (an electrical sensation caused by flexing your neck).
Other sensory symptoms are less specific and described in varying terms, including tingling, pins and needles, numbness, itching, crawling, burning, and pressure or tightness. Symptoms may be a minor annoyance, or alternatively, may be perceived as painful.
Treatments vary. Many patients do not receive any treatments, particularly if they perceive the paresthesia as minor. Medications including tricyclic antidepressants, such as Elavil® (amitriptyline), Neurontin® (gabapentin), or Lyrica® (pregabalin), are often used. When symptoms interfere with quality of life, referral to a physiatrist, a pain specialist, or a physical therapist, may be considered. Fortunately, sensory symptoms are frequently transitory and often resolve on their own.
Q: I have MS and my eyelids now spasm, leading to a diagnosis of blepharospasm. Is this related to my MS?
A: Blepharospasm is a rare condition that has been associated with a number of neurological disorders, including multiple sclerosis. The term blepharospasm refers to bilateral eye twitching or spasm, or involuntary closure. This is different from benign, random unilateral eye twitching, which may occur in many people without any neurological implication, particularly during times of stress, fatigue, or overuse of caffeine or alcohol.
Although the exact cause of blepharospasm can be elusive, it is a movement disorder, probably involving the basal ganglia and facial nerve. The basal ganglia are a cluster of cells located deep in the brain center and are primarily involved with movement functions.
Blepharospasm is generally treated by a neurologist or ophthalmologist. The most common treatment is Botox injected directly into the eyelids. This treatment is generally quite successful. Rarely, when medical treatment is unsuccessful and the condition is severe, surgery can be considered.
Barry A. Hendin, MD, is a highly accomplished neurologist who specializes in MS. He is the chief medical officer for the Multiple Sclerosis Association of America (MSAA) and has spoken at several of MSAA’s educational programs. After 45 years as a neurologist with Phoenix Neurological Associates, Ltd., Dr. Hendin is now director of the Arizona Integrated Neurology MS Center. He is also director of the Multiple Sclerosis Clinic at Banner University Medical Center and clinical professor of neurology at the University of Arizona Medical School.
Please email your “Ask the Doctor” questions to askdr@mymsaa.org