U.S. DEPARTMENT OF HEALTH

AND HUMAN SERVICES

Public Health Service

National Institutes of Health

Multiple 

System 

Atrophy

1

Multiple System Atrophy

What is multiple system atrophy?

Multiple system atrophy (MSA) is a progressive neurodegenerative 

disorder characterized by a combination of 

symptoms that affect both the autonomic 

nervous system and movement. Symptoms 

of autonomic nervous system failure include 

fainting spells and problems with heart rate 

and bladder control. Motor control (movement) dysfunction may feature symptoms 

such as tremor, rigidity, and loss of muscle 

coordination. Some of these symptoms are 

similar to those seen in Parkinson’s disease. 

MSA affects both men and women primarily 

in their 50s. The disease tends to advance 

rapidly over the course of 9 to 10 years, with 

progressive loss of motor skills, eventual 

confinement to bed, and death. There is no 

remission from the disease and there are 

currently no cures.
2

What causes MSA?

T he cause or causes of MSA are unknown. The symptoms reflect the dysfunction 

and eventual loss of nerve cells in several 

different areas in the brain and spinal cord 

that control the autonomic nervous system 

and coordinate muscle movements. The loss 

of nerve cells may be due to the buildup of 

a protein called alpha-synuclein in the cells 

that produce dopamine, a neurotransmitter 

that relays motor commands in the brain. 

The buildup also occurs in other cells called 

oligodendroglia, which help transmit nerve 

signals. MSA, along with Parkinson’s disease 

and some other neurodegenerative conditions, are called synucleinopathies because 

they share a buildup of alpha-synuclein in 

brain cells. 

What are the common signs or symptoms?

The initial symptoms of MSA are often difficult to distinguish from the initial 

symptoms of Parkinson’s disease and include:

•	 decreased spontaneous movement, tremor, 

or rigid muscles; 

•	 clumsiness, loss of balance, and frequent falls;

•	 slurred speech, a croaky, quivering voice, 

or difficulty swallowing; 

•	 fainting or lightheadedness due to orthostatic hypotension, a condition in which 

blood pressure drops rapidly when rising 

from a seated or lying down position; and 

•	 bladder control problems, such as a sudden 

urge to urinate or difficulty emptying the 

bladder completely.
3

Doctors divide MSA into two different types, 

depending on the most prominent symptoms 

at the time an individual is evaluated:

•	 the parkinsonian type (MSA-P) has primary 

characteristics of Parkinson’s disease, 

such as moving slowly, stiff muscles, and 

tremor, along with problems of balance, 

coordination, and autonomic nervous 

system dysfunction; and

•	 the cerebellar type (MSA-C), with primary 

symptoms featuring difficulty swallowing, 

slurred speech, or a quavering voice, along 

with ataxia (problems with balance 

and coordination). 

Some people with MSA may start out with 

the symptoms of one type and then develop 

increasingly more severe symptoms of the 

other type as the disease progresses. Most 

people with MSA will require an aid for 

walking, such as a cane or walker, within a 

few years after symptoms begin. 

Additional symptoms of MSA include:

•	 contractures (chronic shortening of muscles 

or tendons around joints, which prevents 

the joints from moving freely) in the hands 

or feet; 

•	 Pisa syndrome, an abnormal posture in 

which the body appears to be leaning to one 

side like the Leaning Tower of Pisa;

•	 disproportionate antecollis, in which the neck 

bends forward and the head drops down;

•	 deep, uncontrollable sighing or gasping;

•	 inappropriate laughing or crying.
4

How is MSA diagnosed?

Making a positive diagnosis of MSA is difficult, particularly in the early 

stages, because it so closely resembles 

Parkinson’s disease.

After taking a clinical history and performing 

a brief neurological examination, a doctor 

may order a number of tests to help make the 

diagnosis. These tests include autonomic function tests, urine analysis (and other tests to 

assess bladder function), and neuroimaging. 

An MRI (magnetic resonance imaging) of the 

brain is done since there are some changes 

that seem to be specific for MSA. MRI uses 

computer-generated radio waves and a 

powerful magnetic field to produce detailed 

images of body structures including tissues, 

organs, bones, and nerves. A research PET 

scan (positron emission tomography, which 

allows doctors to see how organs and tissues 

are functioning) is sometimes used to see if 

metabolic function is reduced in specific parts 

of the brain that are associated with MSA. A 

DaTSCAN measures dopamine transporter 

cells and can help physicians determine if 

the condition is caused by a dopamine system 

disorder (such as Parkinson’s disease or essential tremor). Individuals with MSA typically 

have no improvement in their symptoms with 

levodopa, a drug used to treat Parkinson’s 

disease, although this lack of response is not 

diagnostic of MSA.
5

How is it treated?

T here is no cure for MSA. Currently, there are no treatments to delay the progress 

of neurodegeneration in the brain. There 

are ongoing treatment trials to evaluate 

drugs that could potentially help delay 

progression. These include rifampicin and 

rasagiline. There are treatments available 

to help people cope with some of the more 

disabling symptoms of MSA. 

The fainting and lightheadedness from 

orthostatic hypotension is often treated 

successfully with simple interventions such 

as adding extra salt to the diet and avoiding 

heavy meals and alcohol. Some people with 

MSA sleep with the head of the bed tilted 

up or use a compression body stocking. The 

drugs fludrocortisone (for those on a high 

salt diet) and midodrine are sometimes 

prescribed to increase blood volume and 

narrow blood vessels. Drinking a glass or 

two of water before getting out of bed in the 

morning can also help raise blood pressure.

Bladder control problems are treated 

according to the nature of the problem. 

Anticholinergic drugs, such as oxybutynin, 

may help reduce the sudden urge to urinate. 

Limiting fluid intake after the evening meal 

and taking desmopressin at night can reduce 

episodes of night-time bedwetting.
6

Difficulties with swallowing and breathing 

eventually require that people with MSA use 

an artificial feeding tube or breathing tube. 

Muscle spasms and contractures usually 

benefit from physical therapy that builds 

strength and encourages people to remain 

mobile for as long as possible.

What research is being done? 

T he National Institute of Neurological Disorders and Stroke (NINDS), a part of 

the National Institutes of Health, supports 

research on MSA through grants to major 

medical institutions across the country. In 

2007, the NINDS sponsored a consensus 

conference that brought together experts 

from around the world to review and update 

the diagnostic criteria for MSA. These new 

diagnostic guidelines are helping doctors 

make quicker and more accurate diagnoses 

of MSA. A great deal of research is ongoing 

to learn why synuclein buildup occurs in 

MSA and Parkinson’s disease, and how to 

prevent it.
7

Where can I find more information on 

MSA and Parkinson’s disease?

For more information on neurological disorders or research programs funded 

by the National Institute of Neurological 

Disorders and Stroke, contact the Institute’s 

Brain Resources and Information Network 

(BRAIN) at:

BRAIN

P.O. Box 5801

Bethesda, MD 20824

800-352-9424

www.ninds.nih.gov

The following organizations support MSA 

research and in some cases may be able to 

provide additional information:

CurePSP (Foundation for PSP|CBD and 

Related Brain Diseases)

30 E. Padonia Road

Suite 201

Timonium, MD 21093

410-785-7004

800-457-4777

www.curepsp.org

Dysautonomia Foundation

315 West 39th Street

Suite 701

New York, NY 10018

212-279-1066

www.familialdysautonomia.org
8

Familial Dysautonomia Hope Foundation, Inc.

121 South Estes Drive 

Suite 205D

Chapel Hill, NC 27514

919-969-6636

www.fdhope.org

National Dysautonomia Research Foundation

P.O. Box 301

Red Wing, MN 55066-0301

651-267-0525

www.ndrf.org

Shy-Drager/Multiple System Atrophy 

Support Group, Inc.

831 Brier Creek Parkway

Suite 105-434

Raleigh, NC 27617

866-SDS-4999 (737-4999)

www.shy-drager.com

Prepared by:

Office of Communications and Public Liaison

National Institute of Neurological 

Disorders and Stroke

National Institutes of Health

Department of Health and Human Services

Bethesda, Maryland 20892-2540

NIH Publication No. 12-5597 March 2012

NIH . . . Turning Discovery Into Health