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PubMed This is a summary of 18 peer-reviewed journal articles Updated
Neurology

Taking Control: Managing the Symptoms of MSA-P

At a Glance

Managing Multiple System Atrophy-Parkinsonian type (MSA-P) requires a proactive, team-based approach to address blood pressure drops, sleep breathing issues, and movement difficulties. Treatment starts with lifestyle changes before introducing targeted medications and therapies.

While there is currently no cure for Multiple System Atrophy - Parkinsonian type (MSA-P), many of the symptoms can be effectively managed to improve your daily quality of life [1]. Management requires a “stepwise” approach, starting with lifestyle changes and moving to medications as needed [1][2].

Managing Blood Pressure and Dizziness

The most common autonomic symptom in MSA-P is neurogenic orthostatic hypotension (nOH)—a drop in blood pressure when standing that causes lightheadedness [3].

  • Non-Drug Strategies: This is the first line of defense. It includes increasing salt and water intake, wearing abdominal binders or thigh-high compression stockings, and performing “counter-maneuvers” like crossing your legs or squeezing your leg muscles when you feel faint [4][5]. Practical Tip: When getting out of bed in the morning, sit on the edge for a few minutes before standing to let your blood pressure adjust.
  • Medications: If lifestyle changes aren’t enough, doctors may prescribe Midodrine, Droxidopa, or Fludrocortisone to help keep your blood pressure up [1][6].
  • The Balancing Act (Supine Hypertension): A major challenge in MSA-P is that blood pressure can become dangerously high when you lie flat (supine hypertension) [7]. To prevent this, you should never lie completely flat. Use a wedge or an adjustable base to keep the head of your bed elevated at a 30- to 45-degree angle [8]. Critical Safety Warning: Because medications like Midodrine and Droxidopa raise blood pressure, they should never be taken within four hours of going to sleep or lying down for a prolonged period [9]. Similarly, avoid consuming high amounts of salt and fluids in the hours immediately before bed to prevent dangerous nighttime blood pressure spikes.

Bladder and Sleep Management

Because MSA-P affects the body’s “automatic” controls, the bladder and breathing systems often need extra support.

  • Urinary Retention: Unlike Parkinson’s, where the bladder is often “overactive,” people with MSA-P often have trouble emptying their bladder completely [10]. If too much urine remains (urinary retention), it can lead to infections. In some cases, a technique called clean intermittent catheterization (CIC) may be recommended to help the bladder empty safely [11].
  • Sleep and Stridor: A high-pitched, whistling sound during sleep—called stridor—is a “red flag” symptom in MSA [12]. It indicates that the vocal cords are partially blocking the airway. This is often managed initially with CPAP (Continuous Positive Airway Pressure) to ensure the airway stays open during the night [13]. However, if non-invasive ventilation like CPAP or BiPAP fails to keep the airway open adequately, a surgical procedure called a tracheostomy is often required as a life-saving measure to safely maintain breathing [14].

Swallowing and Motor Symptoms

As the disease progresses, it can affect the muscles used for eating and basic movement.

  • Dysphagia (Swallowing Issues): Difficulty swallowing can lead to food or liquid entering the lungs, which may cause pneumonia [15]. Early evaluation with a speech therapist and a “swallow study” (videofluoroscopy) is essential [16]. You may need to adjust your diet with thickened liquids or softer foods to remain safe [15].
  • The Levodopa Trial: Even though MSA-P is an “atypical” parkinsonism, most patients start with a trial of levodopa (Sinemet) [17]. While some people with MSA-P see a benefit for a few years, many eventually find that the medication becomes less effective or causes more side effects than it did initially [17]. It is also important to note that levodopa can worsen orthostatic hypotension, complicating your blood pressure management [17].

A Multidisciplinary Approach

The gold standard for care in MSA-P is a team-based approach [1]. This includes a movement disorder specialist, a physical therapist (to help with balance and safe movement), an occupational therapist (to help with daily tasks), and a speech therapist (for swallowing and communication) [4][18]. Early integration of these specialists helps you stay ahead of symptoms rather than reacting to them as they arise.

Common questions in this guide

What is the best way to manage blood pressure drops in MSA-P?
The first line of defense includes increasing salt and water intake, wearing compression stockings, and performing counter-maneuvers like crossing your legs. If lifestyle changes aren't enough, your doctor may prescribe medications like Midodrine or Droxidopa.
Why do I need to keep my head elevated when sleeping with MSA-P?
Many people with MSA-P experience dangerously high blood pressure when lying flat, known as supine hypertension. Sleeping with the head of your bed elevated at a 30- to 45-degree angle helps prevent these nighttime blood pressure spikes.
What is stridor and how is it treated in MSA-P?
Stridor is a high-pitched, whistling sound during sleep caused by the vocal cords partially blocking the airway. It is initially managed with a CPAP machine to keep the airway open at night, though advanced cases may require a tracheostomy.
Does levodopa help with MSA-P movement symptoms?
Most patients with MSA-P will start a trial of levodopa to see if it improves movement. While it can provide some benefit in the early years, it often becomes less effective over time and can worsen blood pressure drops upon standing.
When should I see a specialist for swallowing difficulties?
You should request an evaluation with a speech therapist if you find yourself coughing or clearing your throat frequently during meals. A swallow study can determine if you need to switch to softer foods or thickened liquids to prevent pneumonia.

Questions to Ask Your Doctor

Curated prompts to bring to your next appointment.

  1. 1.How should we adjust my blood pressure medications if my blood pressure is very high when I am lying down (supine hypertension)?
  2. 2.Is it time for a sleep study to check for stridor, even if I haven't noticed any breathing changes myself?
  3. 3.Should I see a urologist for urodynamic testing to check if my bladder is emptying properly?
  4. 4.At what point should we consider a formal swallowing evaluation with a specialist?
  5. 5.How long should we continue the levodopa trial if I am not seeing significant improvement in my movement?

Questions For You

Tap a prompt to share your answer — we'll use it plus this page's context to start a tailored conversation.

References

References (18)
  1. 1

    Management Strategies for Comorbid Supine Hypertension in Patients with Neurogenic Orthostatic Hypotension.

    Isaacson SH, Dashtipour K, Mehdirad AA, Peltier AC

    Current neurology and neuroscience reports 2021; (21(4)):18 doi:10.1007/s11910-021-01104-3.

    PMID: 33687577
  2. 2

    A historical review of multiple system atrophy with a critical appraisal of cellular and animal models.

    Marmion DJ, Peelaerts W, Kordower JH

    Journal of neural transmission (Vienna, Austria : 1996) 2021; (128(10)):1507-1527 doi:10.1007/s00702-021-02419-8.

    PMID: 34613484
  3. 3

    Improving diagnostic accuracy of multiple system atrophy: a clinicopathological study.

    Miki Y, Foti SC, Asi YT, et al.

    Brain : a journal of neurology 2019; (142(9)):2813-2827 doi:10.1093/brain/awz189.

    PMID: 31289815
  4. 4

    Therapeutic Management of the Overlapping Syndromes of Atypical Parkinsonism.

    Giagkou N, Stamelou M

    CNS drugs 2018; (32(9)):827-837 doi:10.1007/s40263-018-0551-3.

    PMID: 30051337
  5. 5

    Ankle plantar-dorsal flexion exercises mitigate orthostatic hypotension in patients with neurodegenerative diseases.

    Akiba T, Terayama K, Ogawa A, et al.

    International journal of rehabilitation research. Internationale Zeitschrift fur Rehabilitationsforschung. Revue internationale de recherches de readaptation 2025; (48(3)):157-165 doi:10.1097/MRR.0000000000000671.

    PMID: 40326447
  6. 6

    Droxidopa for orthostatic hypotension: a systematic review and meta-analysis.

    Strassheim V, Newton JL, Tan MP, Frith J

    Journal of hypertension 2016; (34(10)):1933-41 doi:10.1097/HJH.0000000000001043.

    PMID: 27442791
  7. 7

    Neurogenic orthostatic hypotension and supine hypertension in Parkinson's disease and related synucleinopathies: prioritisation of treatment targets.

    Espay AJ, LeWitt PA, Hauser RA, et al.

    The Lancet. Neurology 2016; (15(9)):954-966 doi:10.1016/S1474-4422(16)30079-5.

    PMID: 27478953
  8. 8

    Characterization of the changes in supine blood pressure with long-term use of droxidopa in patients with neurogenic orthostatic hypotension.

    Hewitt LA, Lindsten A, Gorny S, et al.

    Health science reports 2021; (4(1)):e227 doi:10.1002/hsr2.227.

    PMID: 33521332
  9. 9

    Orthostatic Hypotension in Adults With Hypertension: A Scientific Statement From the American Heart Association.

    Juraschek SP, Cortez MM, Flack JM, et al.

    Hypertension (Dallas, Tex. : 1979) 2024; (81(3)):e16-e30 doi:10.1161/HYP.0000000000000236.

    PMID: 38205630
  10. 10

    Urodynamic Evaluation in Multiple System Atrophy: A Retrospective Cohort Study.

    Eschlböck S, Kiss G, Krismer F, et al.

    Movement disorders clinical practice 2021; (8(7)):1052-1060 doi:10.1002/mdc3.13307.

    PMID: 34631941
  11. 11

    Multiple system atrophy related neurogenic bladder: mechanism and treatment.

    Ren G, Wang Y, Tian H, et al.

    Neurological sciences : official journal of the Italian Neurological Society and of the Italian Society of Clinical Neurophysiology 2025; (46(5)):1965-1976 doi:10.1007/s10072-025-08002-3.

    PMID: 39875674
  12. 12

    Sleep-Disordered Breathing in Multiple System Atrophy: Pathophysiology and New Insights for Diagnosis and Treatment.

    Silvestri R

    Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine 2018; (14(10)):1641-1642 doi:10.5664/jcsm.7360.

    PMID: 30353833
  13. 13

    Respiratory and sleep-related complications of multiple system atrophy.

    Ralls F, Cutchen L

    Current opinion in pulmonary medicine 2020; (26(6)):615-622 doi:10.1097/MCP.0000000000000725.

    PMID: 32925365
  14. 14

    A strategic approach of the management of sleep-disordered breathing in multiple system atrophy.

    Laga A, Bauters F, Hertegonne K, et al.

    Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine 2025; (21(4)):703-711 doi:10.5664/jcsm.11472.

    PMID: 39539061
  15. 15

    Endoscopic Characteristics of Dysphagia in Multiple System Atrophy Compared to Parkinson's Disease.

    Vogel A, Claus I, Ahring S, et al.

    Movement disorders : official journal of the Movement Disorder Society 2022; (37(3)):535-544 doi:10.1002/mds.28854.

    PMID: 34773420
  16. 16

    Esophageal Involvement in Multiple System Atrophy.

    Taniguchi H, Nakayama H, Hori K, et al.

    Dysphagia 2015; (30(6)):669-73 doi:10.1007/s00455-015-9641-2.

    PMID: 26205436
  17. 17

    Levodopa-carbidopa intestinal gel for multiple system atrophy with motor fluctuations: a case series.

    Iseki T, Nishikawa N, Ogawa T, et al.

    Therapeutic advances in neurological disorders 2025; (18()):17562864251360048 doi:10.1177/17562864251360048.

    PMID: 40786524
  18. 18

    Symptomatic therapy of multiple system atrophy.

    Rohrer G, Höglinger GU, Levin J

    Autonomic neuroscience : basic & clinical 2018; (211()):26-30 doi:10.1016/j.autneu.2017.10.006.

    PMID: 29104019

This page provides educational information about managing MSA-P symptoms and does not replace professional medical advice. Always consult your neurologist and care team before adjusting your medications, diet, or sleep routines.

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