Revealing the Uncommon Symptoms of Multiple Sclerosis

You have a recurring headache or hearing loss.  Your first thought is probably not that these are potential symptoms of multiple sclerosis.

But they could be!

When people talk about the symptoms of multiple sclerosis, they naturally tend to focus on the most common symptoms.  But other possible symptoms of MS, which are either uncommon or under-recognized, are not often discussed. Sometimes one of these can even be the presenting (first) symptom of MS. People with neurological symptoms and the doctors attempting to diagnose their case may be unaware that these indicators could be MS related. Also, MS patients might not recognize a medical problem that they are trying to deal with as an MS symptom. In some cases, of course, the symptom may not have any connection to the MS.  That is why it is important to discuss these symptoms and their treatment with your doctor or neurologist.  Once they are recognized, many of the symptoms of MS can be effectively treated. It is also important to remember that not everyone with MS gets these symptoms.

Before looking at the uncommon or under-recognized symptoms of MS, let’s review the symptoms that receive most of the focus:

Even some of these symptoms remain under-recognized and under-treated. Areas such as cognitive issues, emotional problems and sexual dysfunction are often too difficult or embarrassing for the person with MS to discuss with or acknowledge to a doctor.

Other symptoms which are less common (or less recognized) are:

Headaches

Although headaches were once thought to be an infrequent symptom of MS, more recent studies indicate anywhere from 31%¹ to 57.7%² of the test subjects with MS suffered from headaches – the most common being tension-type headaches and migraines. A study of MS pain (including headaches) found that “in 68% [of the subjects] insufficient care by the physicians consulted was reported. This was even true for the most frequent pain, migraine, in which clear treatment recommendations exist. There is thus an urgent need for physicians to keep this problem in mind when treating MS patients.”³ Another study from the University of California Davis Headache Clinic found evidence that suggests “dysfunction within the midbrain/periaqueductal gray matter caused by a demyelinating plaque …increases the incidence of headache in patients with MS”⁴

Hearing Loss

Hearing loss is considered an uncommon symptom of MS, although existing studies tracking its prevalence vary widely in reported occurrence.  The etiology of Sudden Hearing Loss (SHL) recognizes MS, as well as migraines, as a potential neurological cause.  More often, there is a loss in hearing sensitivity.  MRI tests on brain stem lesions showed that whenever a lesion overlapped the auditory pathway, some BinAural (auditory) performance was abnormal.⁵ Other tests show that “up to 40% of MS patients who have normal audiograms experience difficulty hearing in everyday listening conditions” (i.e. background noise).⁶ This can be the difference between hearing sensitivity and processing of auditory information. Those with cognitive symptoms that include difficulty with information processing find that this can influence the ability to filter and process what is heard.

Hearing loss can also occur during an exacerbation, although deafness due to MS is extremely rare and most acute episodes of hearing loss through MS tend to improve.

Sleep Disorders

Sleep disorders are fairly common in people with MS.  One study on sleep disorders in people with multiple sclerosis found that 36% of the test subjects with MS suffered from some form of sleep disorder.⁷ The study also found that age, sex, and degree of disability did not bear any direct relation with sleep disorders. The only symptom of MS the study found that had a direct relationship to problems with sleep was depression. Other studies on fatigue and sleep disorders in people with MS found that there was a significant correlation between fatigue in MS patients and disrupted sleep or abnormal sleep cycles.⁸  It also found a relationship between excessive daytime sleepiness and fatigue in MS patients. Some postulate that stress, spasticity, inactivity and increased need to go to the bathroom also contribute to broken sleep patterns in people with MS.⁹

Vertigo

While dizziness is common in people with MS, vertigo (sensation of spinning) is less so.  One study suggests that, “True vertigo is estimated to occur in about 20% of MS patients.”¹⁰  Lesions in certain areas of the central nervous system can provoke vertigo in patients with MS.  This form of vertigo can be treated, but before that happens other possible forms of vertigo, such as benign paroxysmal positional vertigo (BPPV), should be checked for “in order to avoid unnecessary treatment with corticosteroids and vestibular suppressants.”¹¹

Seizures

Although seizures can occur in MS, they are fairly rare.  Some studies suggest that seizure incidence is the same as, or only slightly more than, the incidence for the general populace.  More than one study shows, however, that seizures in patients with MS can be correlated to alterations in their MRI and EEGs.¹²  One study explains, “These images have shown that epileptic seizures can be caused by cortical and subcortical lesions and by their accompanying oedema.”¹³  Most seizures can be controlled by medication.  According to one study on seizures in patients with MS, “Most of the patients with MS who experienced seizure activity had a benign and transient disorder that was responsive to antiepileptic drug treatment and required no therapy.”¹⁴

Pseudobulbar Affect

Pseudobulbar affect is pathologic laughing and crying, sometimes also called “emotional incontinence”. Some studies suggested that this syndrome may be caused by dysfunction of the prefrontal cortex.¹⁵ One doctor explains, “The frontal lobes are involved in judgment, social propriety and planning, among other things.  When pathologic laughter is seen, other cognitive functions also tend to be lost.”¹⁶ This syndrome has been regulated with Elavil and similar drugs.  Fluoxetine has also been used very successfully and a new drug, Neurodex, will hopefully be available in 2005.¹⁷

Conclusion

Because MS is so variable, it is often difficult to diagnose – especially when the presenting symptom is one not often associated MS.  Yet most of these “unusual symptoms” have at least one documented case showing that symptom as the first MS symptom experienced.  Both doctors and patients should be aware that these symptoms can be related to MS, and almost all can be controlled with the proper treatment. People experiencing these symptoms should discuss them with their doctors and work together to find the best solution for the unusual symptoms of MS.

Endnotes

1 Fryze W, Zaborski J, Czlonkowska A..  Pain in the Course of MS.  Neurol Neurochir Pol 2002 Mar-Apr;36(2):275-84

2 D’Amico D., La Mantia L., Rigamonti A., Usai S., Mascoli N., Milanese C., Bussone G.Prevalence of primary headaches in people with multiple sclerosis. Cephalagia 2004 Nov;24(11):980-4

3 Pollman W, Feneberg W, Erasmus LP.  Pain in MS – A Still Underestimated Problem. Nervenarzt 2002 Feb;75(2):135-40

4 Silberstein, Stephen D, MD.  Highlights of the 45^th Annual Scientific Meeting of the American Headache Society.  Medscape Neurology & Neurosurgery 5(2), 2003.

5 Furst M, Aharonson V, Levine RA, Fullerton BC, Tadmore R, Pratt H, Polyakov A, Korczyn AD. Discrinimation. Effects of Brain Stem Infarcts and Multiple Sclerosis Lesions.Hear Res 2000 May 1;143(1-2):29-42

6 Fausti, Stephen, PhD. Auditory Dysfunction and Multiple Sclerosis: A Silent Concern.  Department of Veterans Affairs, Rehabilitation Research & Development Service.

7 Alarcia R, Ara-Callizo J, Martin J, Lopez A, Bestue M, Bertol V, Vergara J.Sleep Disorders in Multiple Sclerosis.Neurologia 2004 12;19(10):704-709

8 Attarian HP, Brown KM, Duntley SP, Carter JD, Cross AH. The Relationship of Sleep Disturbances and Fatigue in Multiple Sclerosis.  Arch Neurol 2004 Apr;61(4):525-8

9 Grayson, Charlotte, MD.  Multiple Sclerosis:Taking Control of Your Zzzs.Mellen Center for Multiple Sclerosis Research at The Cleveland Clinic and WebMD.May 2004

10 Frohman EM, Kramer PD, Dewey RB, Kramer L, Frohman TC. Benign paroxysmal positioning vertigo in multiple sclerosis:diagnosis, pathology and therapeutic techniques.Mult Scler 2003 Jun;9(3):250-5

11 See Endnote #10

12 Gurtubay IG, Gila L, Morales G, Gallego-Cullere J, Ayuso MT, Manubens JM.Multiple Sclerosis and Epileptic Seizures.Rev Neurol 2000 May 1-15;30(9):827-32

13 Spatt J, Chaix R, Mamoli B.  Epileptic and Non-epileptic Seizures in Multiple Sclerosis. J Neurol 2001 Jan;284(1):2-9

14 Nyquist PA, Cascino GD, Rodriguez M.  Seizures in patients with Multiple Sclerosis seen at Mayo Clinic, Rochester, Minn, 1990-1998.Mayo Clinic Proc 2001 Oct;76(10):983-6

15 Feinstein A, O’Connor P, Gray T, Feinstein K.  Pathological laughing and crying in multiple sclerosis:a preliminary report suggesting a role for the prefrontal cortex. Mult Scler 1999 Apr;5(2):69-73

16 Squillacote D, MD. Pathologic Laughter/Emotional Incontinence.

17 AVANIR Announces Submission of Rolling NDA with Priority Review for Neurodex.San Diego, December 16, 2004.www.avanir.com

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