June 3, 2026 | News | Living with MS MS Research MS Treatments

The New MS – ‘Time is Brain’

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‘Time is brain’ is an idea that emerged following the publication of consensus recommendations on the management of multiple sclerosis (Giovannoni and colleagues. Mult Scler Relat Disord 2016;9:S5-S48). The term was borrowed from stroke medicine where the use of clot-busting medicines within the first few hours after a stroke results in less brain damage and greatly improved recovery. Applying the same idea to MS was meant to emphasize that MS disease activity causes ongoing damage to the brain (over months or years rather than hours), so every effort must be made to minimize this damage. While the paper is now largely outdated, some of its key messages still apply.

The first is that to minimize nerve damage, MS treatment should be started as soon as possible after diagnosis. This will quickly reduce the inflammatory disease activity (relapses and MRI lesions) that causes tissue damage in the central nervous system (CNS). Treatment should obviously be effective, which means that higher-efficacy medications (e.g. Tysabri, Ocrevus or Kesimpta) are often used now as the initial treatment.

Reducing disease activity can reduce the loss of nerve tissue in the brain, which is variously called brain-volume loss (BVL) or brain atrophy. Several MS medications (e.g. Ocrevus, Kesimpta, Lemtrada, Tysabri) have been shown to substantially reduce brain volume loss (Cagol and colleagues. Lancet Reg Health Eur 2025:59:101476). For example, Ocrevus reduced brain-volume loss by 15-22% in the OPERA studies (Hauser and colleagues. N Engl J Med 2017;376:221-234), an effect that was maintained for at least nine years (Cerqueira and colleagues. Neurology 2025;104:e210142).

That said, brain atrophy results are not always easy to interpret because there is not a one-to-one relationship between brain volume and disability. With some medications (e.g. Ocrevus, Kesimpta, Lemtrada) reducing brain-volume loss is associated with a lower rate of worsening disability (Cagol 2025). Other medications (e.g. Aubagio) reduce atrophy but have less impact on disability, while some (e.g. Tecfidera) reduce disability without significantly reducing atrophy. Perhaps a better measure is tissue loss in the grey-matter regions of the brain, which is more closely tied to cognitive impairment. For example, a recent study found that Ocrevus was better than Gilenya in reducing grey-matter atrophy (Bajrami and colleague. J Neurol 2024;271:2149-2158). A separate study reported that Ocrevus was superior to an interferon-beta drug in slowing disability and maintaining cognitive function (Todorovic and colleagues. Acta Neurol Belg 2026, epublished April 13, 2026).

Neurological reserve
In the early days of MS, brain atrophy is not something that a person will notice. The brain changes that occur in MS, such as lesions or atrophy, are generally not accompanied by symptoms so they can be hard to spot. In addition, if there is tissue damage in one part of the brain, the brain can often compensate by rerouting its signals or repurposing brain regions to take on new tasks. This happens with head injuries, during normal aging and in the earlier stages of MS. However, this ability to compensate is a reflection of a person’s neurological reserve. The idea of a neurological reserve is poorly defined but roughly comprises brain size (number of nerve cells, brain volume), your ability to repair damage, and the brain’s ability to adapt to and compensate for damage. Once the reserve is exhausted, the underlying impairments become more evident.

People can protect their neurological reserve with a more brain-healthy lifestyle. The key components of a brain-healthy lifestyle that anyone with MS can adopt are:

1. Maintain your cardiovascular fitness. This includes regular exercise, eating a healthy diet (such as the Mediterranean diet), and controlling cardiovascular risk factors, such as high blood pressure (if you have hypertension), high cholesterol levels and high blood glucose levels (if you are pre-diabetic or diabetic). An MRI study found that aerobic exercise improved the integrity of brain tissue and preserved brain volume, which was associated with better cognitive performance (Prakash and colleagues. Brain Res 2010;1341:41-51). Strength training (20 minutes twice a week) can improve balance, muscle function and walking ability. A routine that incorporates aerobic exercise, mind-body exercise and fun activities (e.g. exer-gaming) has been shown to boost cognitive function in people with MS (Su and colleagues. J Neurol 2025;272:709).

2. Quit smoking. Cigarette smoking has been shown to reduce brain volume and worsen physical and cognitive functioning in people with MS (Kappus and colleagues. J Neurol Neurosurg Psychiatry 2016;87:181-187. D’Hooghe and colleagues. Mult Scler 2010;16:773-785. Ozcan and colleagues. Neuropsychiatr Dis Treat 2014;10:1715-1719).

3. Stay mentally active. The brain needs stimulation to build its capacity to adapt to changes and improvise solutions. Learn something new, take a class, read a book, express your creativity or immerse yourself in a hobby. Enriching your mind can reduce the effects of brain atrophy, preserve mental function and boost memory (Sumowski and colleagues. Neurology 2014;74:1942-1945. Modica and colleagues. Mult Scler 2016;22:36-42).

The key to success is to incorporate these changes into your daily lifestyle rather than make them into a chore on a checklist. Maintaining your brain reserves and preventing further damage with medication are your way to invest in the future. The benefits may not be immediately apparent, but you will have the satisfaction of knowing that you did everything you could to fight your MS.

In Part 3 we will look at the future of MS.

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