Promoting sympathovagal balance in multiple sclerosis; pharmacological, non-pharmacological, and surgical strategies.

Accumulated evidence suggests that cardiovascular autonomic nervous system (ANS) dysfunction may be the underlying cause of many MS clinical presentations, including neurodegeneration and reduced response to immunomodulatory therapies, depression, fatigue and sleep disorders, migraine, osteoporosis, and chronic cerebrospinal venous insufficiency, the newer MS vascular etiology. We have recently described the genetic, epigenetic, and environmental factors with the potential influencing ANS activity, and the interactions among these factors. This review expands upon previous ones, describing the pharmacological, non-pharmacological, and surgical strategies that could be adopted to prevent and minimize the deterioration in ANS function, promoting a state of sympathovagal balance. However, these strategies should not be applied as "one size fits all", but should take into account the nature and the degree of ANS dysfunction. These strategies would be effective in improving ANS function not only in MS, but also in other autoimmune and neurodegenerative diseases, where the dysfunction of this system plays a role.