Multiple system atrophy (MSA)


Multiple system atrophy (MSA) is a rare, degenerative neurological disorder affecting your body's involuntary (autonomic) functions, including blood pressure, breathing, bladder function and motor control.

Formerly called Shy-Drager syndrome, olivopontocerebellar atrophy or striatonigral degeneration, MSA shares many Parkinson's disease-like symptoms, such as slow movement, rigid muscles and poor balance.

Treatment includes medications and lifestyle changes to help manage symptoms, but there is no cure. The condition progresses gradually and eventually leads to death.


Multiple system atrophy (MSA) affects many parts of your body. Symptoms typically develop in adulthood, usually in the 50s or 60s.

MSA is classified by two types: parkinsonian and cerebellar. The type depends on the symptoms you have at diagnosis.

Parkinsonian type

This is the most common type of MSA. The signs and symptoms are similar to those of Parkinson's disease, such as:

  • Rigid muscles
  • Difficulty bending your arms and legs
  • Slow movement (bradykinesia)
  • Tremors (rare in MSA compared with classic Parkinson's disease)
  • Problems with posture and balance

Cerebellar type

The main signs and symptoms are problems with muscle coordination (ataxia), but others may include:

  • Impaired movement and coordination, such as unsteady gait and loss of balance
  • Slurred, slow or low-volume speech (dysarthria)
  • Difficulty swallowing (dysphagia) or chewing

General signs and symptoms

In addition, the primary sign of multiple system atrophy is:


You can also develop dangerously high blood pressure levels while lying down (supine hypertension).

MSA might cause other difficulties with involuntary (autonomic) body functions, including:

Urinary and bowel dysfunction

  • Constipation
  • Loss of bladder or bowel control (incontinence)

Sweating abnormalities

  • Reduced production of sweat, tears and saliva
  • Heat intolerance due to reduced sweating
  • Impaired body temperature control, often causing cold hands or feet

Sleep disorders

  • Agitated sleep due to "acting out" dreams
  • Abnormal breathing at night

Sexual dysfunction

  • Inability to achieve or maintain an erection (impotence)
  • Loss of libido

Cardiovascular problems

  • Color changes in hands and feet caused by pooling of blood
  • Cold hands and feet

Psychiatric problems

  • Difficulty controlling emotions, such as laughing or crying inappropriately

When to see a doctor



There's no known cause for multiple system atrophy (MSA). Some researchers are studying a possible inherited component or involvement of an environmental toxin in the disease process, but there's no substantial evidence to support these theories.


Under a microscope, the damaged brain tissue of people with MSA shows nerve cells (neurons) that contain an abnormal amount of a protein called alpha-synuclein. Some research suggests that this protein may be overexpressed in multiple system atrophy.


The progression of MSA varies, but the condition does not go into remission. As the disorder progresses, daily activities become increasingly difficult.

Possible complications include:

  • Breathing abnormalities during sleep
  • Injuries from falls caused by poor balance or fainting
  • Vocal cord paralysis, which makes speech and breathing difficult
  • Increased difficulty swallowing

People typically live about seven to 10 years after multiple system atrophy symptoms first appear. However, the survival rate with MSA varies widely. Occasionally, people can live for 15 years or longer with the disease. Death is often due to respiratory problems.


Diagnosing multiple system atrophy (MSA) can be challenging. Certain signs and symptoms of MSA — such as muscle rigidity and unsteady gait — also occur with other disorders, such as Parkinson's disease, making the diagnosis more difficult. The clinical examination, with various autonomic tests and imaging studies, can help your doctor determine whether the diagnosis is probable MSA or possible MSA.

As a result, some people are never properly diagnosed. However, doctors are increasingly aware of the disease and more likely to use physical examination and autonomic tests to determine if MSA is the most likely cause of your symptoms.

If your doctor suspects multiple system atrophy, he or she will obtain a medical history, perform a physical examination and possibly order blood tests. Brain imaging scans, such as an MRI, can show signs that may suggest MSA and also help determine if there are other causes that may be contributing to your symptoms.


Tilt table test

This test can help determine if you have a problem with blood pressure control. In this procedure, you're placed on a motorized table and strapped in place. Then the table is tilted upward so that your body is positioned at a 70-degree angle.

During the test, your blood pressure and heart rate are monitored. The findings can document both the extent of blood pressure irregularities and whether they occur with a change in physical position.

Tests to assess autonomic functions

Doctors may order other tests to assess your body's involuntary functions, including:

  • Blood pressure measurement, lying down and standing
  • A sweat test to evaluate perspiration
  • Tests to assess your bladder and bowel function
  • Electrocardiogram to track the electrical signals of your heart

If you have sleep irregularities, especially interrupted breathing or snoring, your doctor may recommend an evaluation in a sleep laboratory. This can help diagnose an underlying and treatable sleep disorder, such as sleep apnea.


There's no cure for multiple system atrophy. Managing the disease involves treating signs and symptoms to make you as comfortable as possible and to maintain your body functions.

To treat specific signs and symptoms, your doctor may recommend:

  • Medications to raise blood pressure. The corticosteroid fludrocortisone and other medications can increase your blood pressure by helping your body retain more salt and water.


    Midodrine (Orvaten) can raise your blood pressure quickly; however, it needs to be taken carefully as it can elevate pressure while lying down. You should not lie flat for four hours after taking the medication.

    The FDA has approved droxidopa (Northera) for treating orthostatic hypotension. The most common side effects of droxidopa include headache, dizziness and nausea.

  • Medications to reduce Parkinson's disease-like signs and symptoms. Certain medications used to treat Parkinson's disease, such as combined levodopa and carbidopa (Duopa, Sinemet, others), can be used to reduce Parkinson's disease-like signs and symptoms, such as stiffness, balance problems and slowness of movement. These medications can also improve overall well-being.

    However, not everyone with multiple system atrophy responds to Parkinson's drugs. They may also become less effective after a few years.

  • Steps to manage swallowing and breathing difficulties. If you have difficulty swallowing, try eating softer foods. If swallowing or breathing becomes increasingly problematic, you may need a surgically inserted feeding or breathing tube. In advanced MSA, you may require a tube (gastrostomy tube) that delivers food directly into your stomach.
  • Therapy. A physical therapist can help you maintain as much of your motor and muscle capacity as possible as the disorder progresses.

    A speech-language pathologist can help you improve or maintain your speech.

Lifestyle and home remedies

Doctors often advise using certain self-care measures to help minimize MSA symptoms, such as:

  • Take steps to raise your blood pressure. Add a little salt to your diet and drink more fluids. Salt and fluids can increase blood volume and raise your blood pressure. Drink coffee and other caffeinated fluids to raise your blood pressure.
  • Elevate the head of your bed. Raising the head of your bed by about 4 to 6 inches will minimize increases in blood pressure when you sleep. Get up slowly from a reclining position.
  • Make dietary changes. Add more fiber to your diet in order to ease constipation. You may also benefit from over-the-counter laxatives. Eat small, low-carbohydrate meals.

Preparing for an appointment

You may have your first appointment to discuss your symptoms with your family doctor, but you may be referred to a doctor who specializes in the diagnosis and treatment of conditions that affect the brain and nervous system (neurologist).

Here's some information to help you prepare for your appointment.

What you can do

  • Write down any symptoms you're experiencing, and for how long. Include all recent changes in your physical or emotional well-being. For example, if you or your loved ones have noticed your moods shifting more quickly, share this with your doctor.
  • Find a family member or friend who can come with you to the appointment, if possible, to help you remember what the doctor says.
  • Write down the questions to ask your doctor.


  • What is likely causing my symptoms?
  • How will you make a firm diagnosis?
  • What tests do I need?
  • What treatment options are available for multiple system atrophy?
  • What are the possible side effects of those treatment options?
  • How is my condition likely to progress?
  • How will you monitor my health over time?

Don't hesitate to ask any other questions that you have.

What to expect from your doctor


  • What are your symptoms?
  • When did you begin having symptoms?
  • Do you feel lightheaded or dizzy when you stand up?
  • Have you ever fainted?
  • Have you noticed any changes in your voice?
  • Have you had problems with bladder control?
  • Have you been constipated?
  • Do you have difficulty chewing or swallowing?
  • Do you have difficulty breathing?
  • Are you being treated for any other health conditions?

What you can do in the meantime

While you wait for your appointment, find out if any blood relatives such as a parent, sibling, or grandparent have been diagnosed with neurological disorders such as Parkinson's disease or cerebellar ataxia. Multiple system atrophy (MSA) is not known to be an inherited condition, so a family history of a condition with similar symptoms may help your doctor rule out MSA.

Last Updated May 21, 2020
