Multiple Sclerosis: Expanding the Field Beyond Management

You see it all over the medical literature: the booming field of multiple sclerosis (MS) research. New news can feel like old news at this point. Still, the vast amount of information is difficult to wrap one’s head around. The best way to grapple with expansive information is through repeated exposure. Thus, this year’s Practical Neurology issue on MS revisits age-old ideas such as optic neuritis and reiterates the more recent science of progressive MS and Bruton tyrosine kinase inhibitors. It also moves beyond MS to its comorbidities and differential diagnoses. The result is a tour through a seemingly ever-expanding universe of applicable data.

The Multiple Sclerosis Prodrome: Past, Present, and Future ponders the possibility of MS signs and symptoms predating the defined disease onset. (Do all patients experience a prodrome? Should I treat my patient to help prevent or delay the first demyelinating event?) One can only imagine what it would be like to have MS before having…MS.

Next is an examination of the neurologic declines that occur in the progressive phase. Contemporary Challenges in the Recognition, Diagnosis, and Management of Progressive Multiple Sclerosis explores the very topics the title suggests. The focus is, classically, on the earlier identification of the RRMS to SPMS transition—all while appreciating that there may be no such distinct states at all! Also on display is Dr. Krieger’s eminent model on the topography of multiple sclerosis, complete with an eloquent narrative to pacify this paradox.

Every action must have a reaction, so next is an examination of the promising new wave of treatments for progressive MS—the realm of Bruton tyrosine kinase inhibitors. Updates in Bruton Tyrosine Kinase Inhibition for Multiple Sclerosis reviews the latest science of these heralded drugs, complete with a background on their mechanism and a brutinib-by-brutinib scrutiny of their current state in the pipeline.

To avoid honing in too much on MS, the broader topic of optic neuritis—often thought to be the start of it all—is discussed. In Considerations for the Management of Optic Neuritis in the Inpatient Setting, the broader view of optic neuritis transports us to the front line, where decisions regarding its acute management are not based solely on thoughts of MS. Next is MOGAD—the latest branch point from MS. The Evolution of Myelin Oligodendrocyte Glycoprotein Antibody-Associated Disease explores the origins of MOGAD, its pathophysiology, common syndromes, prognosis, and treatment options—all while acknowledging that there is still much to be learned about this vastly separate demyelinating disease.

The information so far has most certainly left your head throbbing, and so the final stop is in the world of headache with Management of Headache in People with Multiple Sclerosis. Herein, the disconnect between the high prevalence of headaches in people with MS and the relatively sparse research on their relation is realized. Important questions regarding, for example, the chicken-or-the-egg pathophysiology and the use of monoclonal antibodies to treat migraines in MS, are raised by the authors, who also provide some potential answers.

I thank the authors for their dedication, creativity, and expertise. The authors and I hope you enjoy this review as much as we enjoyed compiling it for you!