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Symptoms and Early Warning Signs of MSA

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Multiple System Atrophy (MSA) symptoms often begin with involuntary system issues before movement problems appear. Early warning signs include REM sleep behavior disorder, sudden blood pressure drops upon standing, bladder control issues, and a high-pitched breathing sound called stridor.

Key Takeaways

  • • REM sleep behavior disorder, where patients physically act out their dreams, can begin years before motor symptoms of MSA appear.
  • • Autonomic failure in MSA frequently causes dizziness when standing (orthostatic hypotension) and early bladder control issues.
  • • Stridor is a high-pitched breathing sound during sleep that indicates a severe risk of breathing obstruction and requires immediate medical attention.
  • • The Cold Hand Sign, where hands turn cold and purplish-blue, is an indicator of autonomic blood flow issues seen in about 20% of patients.
  • • Pain is a common but under-recognized symptom of MSA, particularly in the parkinsonian (MSA-P) subtype.

Understanding the symptoms of Multiple System Atrophy (MSA) involves looking at several different systems in the body simultaneously. Because MSA affects the autonomic nervous system—the part of your brain that controls involuntary functions—symptoms often appear in ways that don’t seem related to movement at first [1][2].

Early Warning Signs: The Sleep Connection

One of the most common early indicators of MSA is REM Sleep Behavior Disorder (RBD) [3]. In people with RBD, the natural paralysis that happens during REM sleep is lost, causing them to physically act out their dreams—often involving shouting, punching, or kicking [4].

Remarkably, RBD can begin years or even decades before the motor symptoms of MSA appear [3][5]. Research shows that up to 91% of people with isolated RBD eventually develop a neurodegenerative condition like MSA [6].

Autonomic Failure: The Defining Feature

Autonomic failure is a hallmark of MSA and often appears early in the disease course [7]. Two of the most significant indicators are:

  • Orthostatic Hypotension (OH): This is a sudden drop in blood pressure when you stand up [7]. It causes dizziness, lightheadedness, or fainting because the brain isn’t receiving enough blood flow [8]. Practical day-to-day strategies can help, such as drinking a glass of water before getting out of bed, and standing up slowly in stages to give your blood pressure time to adjust [9].
  • Genitourinary Dysfunction: For many, bladder issues like urinary urgency, frequency, or urinary incontinence (loss of bladder control) are the first symptoms, sometimes appearing nearly three years before movement issues [10][11]. In men, erectile dysfunction is also a common early sign [12].

The “Cold Hand Sign”

The Cold Hand Sign is a specific physical marker seen in about 20% of MSA patients [13]. It is characterized by hands that are cold to the touch and often take on a purple or reddish-blue color (cyanosis) [13][14]. This occurs because the autonomic system is not properly regulating blood flow to the extremities. Identifying this sign early can be important, as it is often associated with a more rapid disease progression [13].

Stridor: A Critical Warning Sign

Stridor is a high-pitched, strained, or “crowing” sound made during breathing, usually while asleep [15]. It is caused by a narrowing of the larynx (voice box) due to muscle weakness [15][16].

Stridor is considered a critical symptom because it indicates a risk for severe breathing obstruction [17]. It is found in over 63% of MSA patients and is associated with a higher risk of “early critical events” [15][17]. If you or a caregiver notice this sound, it should be reported to a neurologist immediately [15].

Managing Pain in MSA

While MSA is often thought of as a movement disorder, pain is a very common but under-recognized symptom [18]. Approximately 67% of people with MSA experience significant pain [18].

  • Subtype Differences: Pain is much more common in the MSA-P (parkinsonian) subtype, affecting about 76% of patients, compared to 45% of those with the MSA-C (cerebellar) subtype [18].
  • Locations: The most common sites for pain include the limbs, neck, and back [19].

Because pain in MSA is often undertreated, it is vital to discuss any discomfort with your care team, as specialized therapies and management strategies are available [18][20].

Frequently Asked Questions

What are the very first signs of MSA?
The earliest signs of Multiple System Atrophy often involve the autonomic nervous system rather than movement. Many patients first experience REM sleep behavior disorder, urinary incontinence, or sudden drops in blood pressure when standing up.
What is the 'Cold Hand Sign' in MSA?
The Cold Hand Sign is a physical symptom where the hands become cold to the touch and turn a purple or reddish-blue color. This happens because the autonomic nervous system struggles to properly regulate blood flow to the extremities.
Why do people with MSA make a high-pitched sound while sleeping?
This sound, known as stridor, is caused by muscle weakness that narrows the voice box during sleep. It is a critical warning sign that requires immediate medical evaluation to prevent severe breathing obstruction.
Does Multiple System Atrophy cause pain?
Yes, significant pain is common in MSA, affecting over half of patients. It is especially frequent in the parkinsonian subtype (MSA-P) and typically occurs in the limbs, neck, and back.
How does MSA affect blood pressure?
MSA frequently causes orthostatic hypotension, which is a sudden drop in blood pressure when standing up. This can lead to dizziness, lightheadedness, or fainting due to reduced blood flow to the brain.

Questions for Your Doctor

  • • Has a sleep study (polysomnography) been performed to check for stridor or REM sleep behavior disorder?
  • • Is my pain related to the MSA-P subtype, and what are the best options for managing it?
  • • Can you explain how my bladder issues and blood pressure drops (orthostatic hypotension) relate to the autonomic failure seen in MSA?
  • • If you observe the 'Cold Hand Sign,' what does that tell us about my specific disease progression?
  • • Are my breathing patterns during sleep high-risk, and should we consider treatments like CPAP or a referral to a sleep specialist?

Questions for You

  • • Have I noticed my hands or feet becoming cold and turning a purple or reddish-blue color?
  • • Has my partner noticed me making a high-pitched, 'crowing' sound while I sleep?
  • • Do I experience dizziness or lightheadedness every time I stand up?
  • • Am I having trouble with urinary urgency or accidents that started around the same time as my movement changes?

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This page explains symptoms of Multiple System Atrophy (MSA) for educational purposes. Always consult a neurologist or sleep specialist for an accurate diagnosis and treatment plan.

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