Background: Phase 3 COMET trial (NCT02782741) compares avalglucosidase alfa (n=51) with alglucosidase alfa (n=49) in treatment-naïve LOPD. Methods: Primary objective: determine avalglucosidase alfa effect on respiratory muscle function. Secondary/other objectives include: avalglucosidase alfa effect on functional endurance, inspiratory/expiratory muscle strength, lower/upper extremity muscle strength, motor function, health-related quality of life, safety. Results: At Week 49, change (LSmean±SE) from baseline in upright forced vital capacity %predicted was greater with avalglucosidase alfa (2.89%±0.88%) versus alglucosidase alfa (0.46%±0.93%)(absolute difference+2.43%). The primary objective, achieving statistical non-inferiority (p=0.0074), was met. Superiority testing was borderline significant (p=0.0626). Week 49 change from baseline in 6-minute walk test was 30.01-meters greater for avalglucosidase alfa (32.21±9.93m) versus alglucosidase alfa (2.19±10.40m). Positive results for avalglucosidase alfa were seen for all secondary/other efficacy endpoints. Treatment-emergent adverse events (AEs) occurred in 86.3% of avalglucosidase alfa-treated and 91.8% of alglucosidase alfa-treated participants. Five participants withdrew, 4 for AEs, all on alglucosidase alfa. Serious AEs occurred in 8 avalglucosidase alfa-treated and 12 alglucosidase alfa-treated participants. IgG antidrug antibody responses were similar in both. High titers and neutralizing antibodies were more common for alglucosidase alfa. Conclusions: Results demonstrate improvements in clinically meaningful outcome measures and a more favorable safety profile with avalglucosidase alfa versus alglucosidase alfa. Funding: Sanofi Genzyme

Background: Real world use of oral prophylactic migraine therapies is often limited by poor patient tolerance. The objective of this study was to describe the demographics and clinical characteristics of patients prescribed erenumab following its launch in Canada (September 2018) and to evaluate the real-world treatment persistence and dose management. Methods: This was a retrospective, descriptive analysis of de-identified secondary patient data that includes baseline demographics, clinical characteristics, plus erenumab treatment management, collected through Novartis’ Go Program® (Patient Support Program). Only data collected from patients with a documented informed consent were included in the analysis. Results: 14,282 patients met eligibility criteria. The mean age of patients was 46.3 years, 83.0% were female, and 66.1% reported having ≥15 monthly migraine days. 52.5% were initiated on the 140 mg dose of erenumab and 59.3% of those who initiated the 70 mg dose escalated to 140 mg within 360 days. After 360 and 450 days, the KM-derived persistence was 71.0% and 63.4%, respectively. Conclusions: The high persistence reported here suggests that erenumab has a meaningful degree of tolerability in the real-world setting and increases confidence that the real-world use and benefits of erenumab will not be undermined by the poor persistence observed with traditional migraine prophylactic agents.

Background: Eptinezumab is approved for migraine prevention, with demonstrated rapid onset of preventive benefit. RELIEF evaluated the efficacy and safety of eptinezumab initiated during a migraine attack. Methods: RELIEF (NCT04152083; parallel-group, double-blind, placebo-controlled) randomized adults with migraine (4-15d/mo in 3mo prior to screening) to eptinezumab 100mg or placebo, administered IV within 1-6h of qualifying migraine onset. Co-primary efficacy endpoints were time to headache pain freedom and time to absence of most bothersome symptom (MBS). Results: Eptinezumab (n=238) compared with placebo (n=242) achieved significantly faster headache pain freedom (median 4h vs 9h; hazard ratio=1.54, P=0.0006) and absence of MBS (2h vs 3h; 1.75, P<0.0001). At 2h, 23.5% and 12.0% (P=0.0009) of eptinezumab-treated and placebo patients, respectively, reported headache pain freedom, and 55.5% and 35.8% (P<0.0001) reported absence of MBS. Significantly fewer eptinezumab-treated patients used rescue medication within 24h (31.5% vs 59.9%; P<0.0001). Treatment-emergent adverse events occurred in 10.9% eptinezumab-treated and 10.3% placebo patients; no serious adverse events occurred. Conclusions: Infusion of the preventive migraine treatment, eptinezumab, during a migraine resulted in rapid and sustained freedom from headache pain and MBS vs placebo, starting 2h post-infusion, decreasing need for acute medication within 24h post-infusion. No notable safety findings were identified.

Background: Idiopathic intracranial hypertension (IIH) is a condition of increased intracranial pressure in the absence of a space-occupying lesion. The goal of this study is to investigate which factors may influence outcomes in order to improve surgical strategy. We hypothesized diabetes, hypertension, smoking, and obesity influence patients prognosis. Methods: This retrospective chart review included patients diagnosed with IIH who underwent surgical intervention. All patients receiving surgery between 2008 and 2018 were included, and divided into 2 cohorts. Cohort 1 representing favorable course and cohort 2 representing unfavorable course. Favorable course was defined as requiring single surgery for management. Unfavorable course required multiple surgical revisions. Results: Overall, 35/48 (73%) comprised the favorable group. Thirteen patients (27%) comprised the unfavorable group. Of the unfavorable group, 54% had LP shunts, with the remaining receiving VP shunts. There was no association between type of shunt and outcome. Common issues the unfavorable group encountered were persisting symptoms, infections, obstruction of shunt and replacement of shunt. Smoking and frequent follow-up were associated with unfavorable course. Gender, BMI, age, comorbidities and shunt type were not associated with outcome. Conclusions: We found smoking and patient follow-up had a significant association with unfavorable outcome. Other factors had no association with patient outcome.

Background: The goal of the study was to assess responder rates at various times after initiating atogepant treatment. Methods: A 12-week phase 3 trial evaluated the safety, efficacy, and tolerability of atogepant for preventive treatment of migraine (ADVANCE; NCT03777059) in adult participants with a ≥1-year history of migraine, experiencing 4-14 migraine days/month. Participants were randomized to atogepant 10, 30, or 60mg, or placebo once daily. These analyses evaluated ≥25%, ≥50%, ≥75%, and 100% reductions in mean monthly migraine days (MMDs) across 12 weeks and each 4-week interval. Adverse events (AEs) in ≥5% of participants are reported. Results: The efficacy analysis population included 873 participants: placebo: n=214; atogepant: 10mg: n=214; 30mg: n=223; 60mg: n=222. Atogepant-treated participants were more likely to experience a ≥50% reduction in the 3-month mean MMDs (56-61% vs 29% with placebo; P<0.0001). The proportions of participants experiencing ≥25%, ≥50%, ≥75%, and 100% reductions in mean MMDs significantly increased during each 4-week interval (≥50% reduction: 48-71% vs 27-47% with placebo). The most common AEs for atogepant were constipation (6.9-7.7%) and nausea (4.4-6.1%). Conclusions: Once-daily atogepant 10, 30, and 60mg significantly increased responder rates at all thresholds with approximately 60% achieving a ≥50% reduction in mean MMDs at 12 weeks.

Background: The goal of the study was to assess the safety and tolerability of atogepant, an oral, calcitonin gene-related peptide receptor antagonist in development for migraine preventive treatment, once daily over 1 year. Methods: Multicenter, open-label trial (NCT03700320). Adults with migraine were randomized 5:2 to atogepant or oral standard-of-care (SOC) migraine prevention. Results: 744 randomized participants (n=546 atogepant), 739 safety population participants (n=543 atogepant). Adverse events (AEs) were reported by 67.0% of atogepant participants; 18.0% had AEs considered related to atogepant. AEs reported by ≥5% of atogepant-treated participants were upper respiratory tract infection (10.3%), constipation (7.2%), nausea (6.3%), and urinary tract infection (5.2%). 4.4% of atogepant participants reported serious AEs that included various, common medical conditions; no event occurred in ≥1 participant and none were atogepant-related. Two deaths were reported in atogepant-treated participants (homicide victim; toxic shock syndrome); both were considered not treatment-related. 5.7% of atogepant participants discontinued due to AEs. Alanine aminotransferase/aspartate aminotransferase levels ≥3X upper limit of normal were reported for 2.4% of atogepant participants (n=13/531) and 3.2% of SOC participants (n=6/190). No cases of potential Hy’s Law were reported. Conclusions: Once-daily use of atogepant for preventive treatment of migraine over 1 year was safe and well-tolerated with no safety concerns identified.

Background: Pyomyositis is an infectious disease usually encountered in tropical regions. It typically occurs in immunocompromised hosts and most commonly affects lower limb muscles. Our patient was a healthy Canadian with an atypical presentation of cervical pyomyositis. Methods: We report a case of a healthy 22-year old woman presenting to the emergency department with unprovoked severe bilateral cervico-occipital pain and nuchal rigidity. She remained afebrile. Review of the literature was conducted to search for similar presentations. Results: A Computed Tomography scan of the head and neck demonstrated the presence of a ring enhancing lesion in the semispinalis capitis muscle extending from the occiput to the C4 level. The abscess was surgically drained and cultures grew staphylococcus aureus. The patient rapidly improved on intravenous antibiotics. Literature review revealed this to be the first Canadian case of cervical pyomyositis. Conclusions: Cervical pyomyositis can be complicated by local destruction of the vertebrae, septic shock, endocarditis, septic emboli, brain abscess or rhabdomyolysis. Early diagnosis and source control is necessary to reduce the risk of morbidity. Therefore, it is important to consider this rare disease in the differential diagnosis of cervicalgia even in healthy immunocompetent patients.

Background: Eptinezumab is approved in the US for the preventive treatment of migraine and was well tolerated in double-blind, placebo-controlled studies in patients with episodic and chronic migraine (CM). The PREVAIL study evaluated the long-term safety, immunogenicity, and impact on patient-reported outcomes of repeat doses of eptinezumab in patients with CM. Methods: PREVAIL was an open-label, phase 3 trial comprising two 48-week treatment phases. Adults with CM received eptinezumab 300 mg by 30-minute IV every 12 weeks for ≤8 doses, with patients followed up to week 104. Results: 128 adults (mean age, 41.5y) with CM were treated. Over 2 years, the most frequently reported treatment-emergent adverse events were nasopharyngitis (14.1%), upper respiratory tract infection (7.8%), sinusitis (7.8%), influenza (6.3%), bronchitis (5.5%), and migraine (5.5%). Study-drug discontinuation due to adverse events was 6.3%. Anti-eptinezumab antibody incidence peaked at week 24 and declined despite continued dosing, to nondetectable levels at week 104. Patient-reported outcomes were improved at first assessment (week 4) and generally sustained through week 104. Conclusions: In adults with CM, eptinezumab 300 mg demonstrated a favorable safety profile, limited long-term immunogenicity, early and sustained reductions in migraine-related burden, and improvements in health-related quality of life over 2 years.

Background: Eptinezumab is a preventive migraine treatment approved in the US. We evaluated the impact of eptinezumab on acute headache medication (AHM) use in patients diagnosed with chronic migraine (CM) and medication-overuse headache (MOH) in PROMISE-2. Methods: PROMISE-2 randomized patients with CM to eptinezumab 100mg, 300mg, or placebo for 2 intravenous doses administered every 12 weeks. Trained investigators diagnosed MOH at screening using 3-month medication history and ICHD-3b criteria. Endpoints included days/month of any AHM use (days of ≥1 medication class), total AHM use (summed days for each medication class), and triptan use over Weeks 1-12 and 13-24. AHM classes included triptan, ergot, opioid, simple analgesic, and combination analgesic. Results: Of 1072 PROMISE-2 patients, 431 (40.2%) were diagnosed with MOH (100mg, n=139; 300mg, n=147; placebo, n=145). During the 28-day baseline period, mean days of any AHM was ~16.4, total AHM was ~20.4, and triptan was ~8.9 across treatment arms. Over Weeks 1-12, mean days/month of any AHM was 8.8 (100mg), 9.9 (300mg), and 11.8 (placebo); total AHM was 10.8, 12.2, and 14.8; triptan was 4.3, 4.4, and 6.4. Similar or lower rates were observed over Weeks 13-24. Conclusions: In patients diagnosed with both CM and MOH, eptinezumab treatment reduced AHM use.

Background: Eptinezumab is approved in the US for migraine prevention. We demonstrate the consistency in migraine reduction from Day 1 across 4 weeks in patients with episodic (EM) or chronic migraine (CM) treated with eptinezumab. Methods: Four double-blind, placebo-controlled, randomized trials evaluated eptinezumab for migraine prevention: NCT01772524 (EM); NCT02559895 (EM, PROMISE-1); NCT02275117 (CM); NCT02974153 (CM, PROMISE-2). The percentage of patients experiencing migraine was evaluated on Day 1, then as an averaged daily occurrence weekly through Wk4; baseline was averaged over the 28-day screening period. Results: Approximately 31% of EM patients experienced migraine on any given day during baseline. PROMISE-1 percentages of patients with migraine on Day 1: 14.8% (100mg), 13.9% (300mg), 22.5% (placebo); during Wk4: 17.1%, 15.8%, 20.5%. NCT01772524 on Day 1: 4.8% (1000mg), 13.7% (placebo); during Wk4: 10.0%, 17.6%. Approximately 58-59% of CM patients experienced migraine on any given day during baseline. PROMISE-2 percentages on Day 1: 28.6% (100mg), 27.8% (300mg), 42.3% (placebo); during Wk4: 31.8%, 28.8%, 36.0%. NCT02275117 on Day 1: 29.3% (100mg), 26.5% (300mg), 48.7% (placebo); during Wk4: 30.2%, 30.1%, 41.0%. Conclusions: Across 4 migraine prevention trials, eptinezumab consistently demonstrated rapid onset of migraine preventive benefit, beginning Day 1 after initial treatment and sustained through ≥4 weeks.

Background: Migraine is costly to governments. Despite significant burden, Canada lacks population data regarding migraine prevalence, resource and medication utilization. We sought to characterize the demographics, health resource utilization, and medication use in an adult migraine cohort in Alberta. Methods: Migraine cohort: previously validated case definition of migraine (ICD 10 + dispensation of abortive and/or preventative migraine drug (04/2010-03/2016). Patients over 18 years, followed three years from index date [first dispensation of migraine medication]. Health resource utilization (HRU) assessed by emergency department (ED) visits, hospital admission and physician claims. Medication assessed province-wide dispensation database linkage. Patient demographics and Charlson Comorbidity Index (CCI) included. Results: Over 5 years: 53,333 migraine cases identified (mean age 40.5 years, 79% female). Common comorbidities: hypertension, COPD, diabetes mellitus, cancer, cerebrovascular disease. Mean CCI 0.55 (SD 1.06). Metropolitan patients: 48%, urban 34.6%, rural 17.4%. Initial migraine diagnosis: 46% by GP, 31% in ED. Rural patients present more to ED/hospital for care in 3-year follow-up (IRR 2.95 [2.83, 3.08]). Conclusions: Our migraine case definition is more specific than sensitive and underestimates Alberta’s migraine prevalence. Higher female prevalence as expected. Rurally, migraine care largely occurs in ED/hospital. Study of prevalence, HRU and medications may help inform health policy in Alberta and Canada.

Background: There are limited Canadian data on the impact of migraine on quality of life, economic, and societal burden. Therefore, the aim of this study was to characterize the humanistic and economic burden of illness of migraine in Canada. Methods:Retrospective medical chart review and prospective patient survey were used to evaluate the clinical, social, and economic burden of migraine in patients who failed at least two prior prophylactic therapies.Results: 287 migraine patients were included. High- frequency episodic migraine (8 to 14 MMDs) and chronic migraine (15+ MMDs) made up the majority of the cohort (35.2% and 35.9%, respectively). 72.8% of the patients had underlying comorbidities 78% indicated that they experienced severe disability on their daily life due to their headaches. The total estimated annual cost of chronic migraine was $25,669 per patient while high-frequency episodic and low-frequency episodic migraine was associated with an annual cost of $24,885 and $15,651 per patient respectively. Conclusions: This study provides a recent and comprehensive assessment of the burden of illness associated with migraine in Canada and showed that migraine is associated with a substantial humanistic and economic burden for patients and healthcare systems.

Background: The sustained effects of onabotulinumtoxinA in patients with cervical dystonia (CD) who were naïve or non-naïve to botulinum toxin at enrollment in CD PROBE (CD Patient Registry for Observation of BOTOX® Efficacy) were evaluated. Methods: Patients were included if they completed all three treatment cycles and had accompanying data in this prospective, observational study. Assessments included CD severity, Cervical Dystonia Impact Profile (CDIP-58), Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS), treatment interval, total dose, and adverse events (AEs). Results: Changes in severity following each onabotulinumtoxinA treatment were generally similar between naïve (n=212) and non-naïve (n=138) patients. Severity scores were maintained or improved in most patients with mild/moderate symptoms, while 30.0-66.7% with the highest severity scores shifted to a lower score across treatments. Sustained improvements were seen in all CDIP-58 subscales and TWSTRS total scores irrespective of baseline CD severity and toxin status. The median time interval between injections was similar in naïve (93.0–98.0 days) and non-naïve patients (96.0–97.0 days); doses tended to be lower in naïve patients. The most common AEs (dysphagia, muscular weakness) were similar. Conclusions: CD severity was attenuated by repeat onabotulinumtoxinA treatments at consistent intervals regardless of prior botulinum toxin exposure. Treatments were well tolerated.

Background: The impact of cervical dystonia (CD) severity on presentation subtype and onabotulinumtoxinA utilization was examined in the completer population from CD PROBE (CD Patient Registry for Observation of BOTOX® Efficacy). Methods: In this multicenter, prospective, observational registry, patients with CD were treated with onabotulinumtoxinA according to injectors’ standard of care. Completers were patients that completed all 3 treatment sessions and had accompanying data. Results: Of N=1046 patients enrolled, n=350 were completers. Completers were on average 57.3 years old, 74.9% female, 94.6% white, and 60.6% toxin-naïve. Baseline severity was mild in 32.6%, moderate in 54.3%, and severe in 13.1%. Torticollis was the most common presentation at baseline (mild: 44.7%, moderate: 55.8%, severe: 63.0%), followed by laterocollis (mild: 42.1%, moderate: 32.6%, severe: 26.1%). Median onabotulinumtoxinA dose increased over time; 160U–200U for torticollis and 170U–200U for laterocollis. For all severities, median total dose increased from injection 1 to injection 3 (mild: 138U–165U, moderate: 183U–200U, severe: 200U–285U). Eighty-one patients (23.1%) reported 139 treatment-related adverse events. There were no treatment-related serious adverse eventsand no new safety signals. Conclusions: CD severity impacted presentation subtype frequency and onabotulinumtoxinA utilization in CD PROBE, with higher and tailored dosing observed over time and with increasing disease severity.

Background: There is no biological marker of progression in early Parkinson Disease (PD). Upper limb (UL) tremor is the most common motor symptom at onset. The significance of lower limb (LL) tremor remains unknown. We report on longitudinally followed autopsy-verified PD tremor onset cases. Methods: A chart review of longitudinally followed autopsy-verified PD cases was performed. Age and mode of onset were recorded at initial evaluation. Prognosis was measured by change in Hoehn and Yahr scale while on levodopa (LD). Results: Fourty-nine patients were included. Thirty-eight cases had upper limb (UL), four lower limb (LL), and seven upper and lower limb (ULL) onset tremor. UL had 86.8% response to LD, LL 50% and ULL 85.7%. Sub-analysis of UL responders found 20% mild improvement, 53.3% moderate and 26.7% marked. ULL had moderate response in 83.3% and marked in 16.7%. LL responders only had mild improvement with LD. Conclusions: Tremor onset is most common in UL, followed by ULL and then LL. LL onset tremor cases have an inferior response to LD when compared to UL and ULL cases.

Background: While researchers pursue the etiology, pathophysiology and treatment of movement disorders, presently there is no biological marker for the two most common disorders – essential tremor (ET), and Parkinson’s disease and variants (Parkinson syndrome, or PS). The diagnosis of each remains clinical, but definitive diagnosis is made on brain pathology. Population epidemiological studies are hampered by a lack of diagnostic precision. Twins with the same disorder are scarce, and the next best option is studies of well-documented first-degree family members. Methods: Patients were seen at the Saskatchewan Movement Disorders Program (SMDP). All autopsied cases with known clinicopathological diagnosis of a movement disorder between 1970 and 2019 were reviewed. Only those with a first-degree family member – parent, child, and/or sibling - with a movement disorder were included. Results: 671 cases with movement disorders seen at SMDP have been autopsied. 29 cases including probands were found and thirteen first-degree families were identified; eight families were multiple (2 or more) siblings and five families included one parent/one child. In seven families, the diagnosis was concordant. Conclusions: Movement disorders in first degree relatives with autopsied verified diagnosis are dissimilar in nearly half the cases. Such small intensively studied groups offer unique research opportunities.

Background: Dopamine Dysregulation Syndrome (DDS) is an adverse non-motor complication of dopamine replacement therapy in Parkinson’s Disease. The current literature on DDS is limited, and it remains underdiagnosed and challenging to manage. Methods: We performed a retrospective chart review and classified patients according to risk factors that have been identified in the literature, UPDRS scores, intervention and outcome. Univariate analyses were performed to quantify these characteristics. Results: Prior psychiatric illness was identified in 70% of patients, impulse control disorder in 89% and substance abuse in 3.7%. Interventions included reduction of dopamine therapy (88.9%), deep brain stimulation (DBS) of the subthalamic nucleus (STN, 48.1%) or globus pallidus interna (GPi, 7.4%), and levodopa-carbidopa intestinal gel (LCIG) infusion (11.1%). Baseline UPDRS IV before treatment and MDS III after treatment were not significant between intervention groups (p=0.09 and p=0.13 respectively). Overall 88.9% patients improved at follow up, with medication only (75%), STN DBS (100%), GPi DBS (100%) and LCIG (33%). Relapse rate was 18.2%, in the STN group only. Conclusions: Our results suggest that GPi DBS, in concurrence with dopaminergic medication reduction, is the most effective intervention. STN DBS might be also beneficial although the associated medications reduction causes DDS relapse in a subgroup of patients.

Background: Prognostic biomarkers are badly needed to direct MS treatment intensity early in the condition Levels of serum neurofilament light chains (sNfL) result from the destruction of central nervous system axons in MS and correlate with the aggressiveness of the disease. Methods: In this prospective cohort study, we identified patients with serum collected within 5 years of first MS symptom onset with more than 15 years of clinical follow-up. Levels of sNfL were quantified in patients and matched controls using digital immunoassay. Results: Sixty-seven patients had a median follow-up period of 17.4 years (range:15.1-26.1). Median serum NfL levels in baseline samples of MS patients was 10.1 pg/ml, 38.5% higher than median levels in 37 controls (7.26pg/ml, p=0.004). Baseline NfL level was most helpful as a predictive marker to rule out progression; patients with levels less 7.62pg/ml were 4.3 times less likely to develop an EDSS score of 34 (p=0.001) and 7.1 times less likely to develop progressive MS (p=0.054). Patients with the highest NfL levels (3rd-tertile, >13.2 pg/ml) progressed most rapidly with an EDSS annual rate of 0.16 (p=0.004), remaining significant after adjustment for sex, age, and disease-modifying treatment (p=0.022). Conclusions: This study demonstrates that baseline sNfL is associated with long term disease progression.

Background: Despite the availability of cell-based assays for aquaporin-4 (AQP4) and myelin oligodendrocyte glycoprotein (MOG) antibodies provincially, outside confirmatory testing is often performed (typically Mayo Clinic Laboratories, USA) when results deviate from expected. It is unknown how often this costly undertaking (upwards of $1,200 CAN) alters diagnosis and management. Methods: We undertook a quality improvement project evaluating the concordance/discordance rate with select chart review in all patients who had cell-based AQP4 or MOG IgG antibody testing at Mitogen Diagnostics (MitogenDx; Calgary, Alberta) and subsequent testing at Mayo Clinic Laboratories from as early as 2010 to July 2020. Results: Preliminary review of data from January 2016 to July 2020 retrieved 145 paired tests; 10 of which were discordant (concordance rate: 93.1%). Chart review confirmed 9 truly discordant cases, often associated with AQP4 or MOG weak-positive results (7/9 cases) or presumed false negative AQP4 results in prototypical neuromyelitis optica spectrum disorder (2/9 cases). Conclusions: Discordant results were rare when comparing MitogenDx local AQP4/MOG antibody test results to those referred out to Mayo Clinic Laboratories, impacting diagnosis and treatment in only 3 patients out of the total. Our results suggest costly outside confirmatory testing of AQP4/MOG antibodies could be reduced.

Background: Standardized magnetic resonance imaging (MRI) guidelines published in 2015 by the Europoean MAGNIMS group and in 2016 by the CMSC are important for the diagnosis and monitoring of patients with multiple sclerosis (MS) and for the appropriate use of MRI in routine clinical practice. Methods: Two panels of experts convened to update existing guidelines for a standardized MRI protocol. The MAGNIMS panel convened in Graz, Austria in April 2019. The CMSC NAIMS panel met separately and independently in Newark, USA in October 2019. Subsequently, the MAGNIMS, NAIMS, and CMSC working groups combined their efforts to reach an international consensus Results: The revised guidelines on MRI in MS merges recommendations from MAGNIMS, CMSC, and NAIMS to improve the use of MRI for diagnosis, prognosis and monitoring of individuals with MS. 3D acquisitions are emphasized for optimal comparison over time. Core brain sequences include a 3D-T2wFLAIR for lesion identification and monitoring treatment effectiveness. Gadolinium-based contrast is recommended for diagnostic studies and judicious use for routine monitoring of MS patients. DWI sequences are recommended for PML safety monitoring. Conclusions: The international consensus guidelines strive for global acceptance of a useful and usable standard of care for patients with MS.