Multiple sclerosis (MS) is a chronic autoimmune illness characterized by inflammation and demyelination of the central nervous system (CNS). The effective delivery of therapeutic agents to the CNS continues to be an important barrier in MS treatment due to the blood-brain barrier and limited access to the affected areas. Exosome-based drug delivery systems have become an attractive option for targeted therapy in MS. Exosomes, small extracellular vesicles derived from various cell types, possess unique biological properties that make them ideal nanocarriers for delivering therapeutic cargo to specific cell populations in the CNS. In this study, we supply a comprehensive overview of the current advances and future perspectives of exosome-based drug delivery systems for MS. We discuss the biogenesis of exosomes, strategies for cargo loading, engineering approaches to enhance their targeting capabilities, and the potential clinical applications of exosome-mediated drug delivery in MS therapy. Additionally, we explore preclinical studies and animal models that demonstrate the effectiveness of exosome-based drug delivery in ameliorating MS pathology. By highlighting the challenges and opportunities in utilizing exosomes as drug delivery vehicles, this review aims to contribute to the growing body of knowledge in the field of nanomedicine for MS. Considering the potential of exosome-based drug delivery systems to enhance the accessibility, specificity, and effectiveness of therapies while minimizing off-target effects might change the therapeutic scenario for MS.