Medically reviewed by Dr. Mitesh Chandarana | Last updated: August 2026
Sleep disturbances are among the most common and most under-discussed symptoms in Multiple System Atrophy (MSA). Research suggests up to 70% of MSA patients experience some form of sleep disorder, ranging from simple insomnia to more serious breathing-related issues during sleep. Because MSA affects the autonomic nervous system alongside movement, its sleep problems are often different in nature and in importance from the sleep issues seen in Parkinson’s disease.
This guide covers the specific sleep-related symptoms seen in MSA, why they happen, and how they’re managed including one symptom in particular that’s important for every MSA patient and caregiver to understand.
Why Sleep Is Affected Differently in MSA
MSA damages brain regions and circuits that regulate both movement and many automatic body functions including the ones that control breathing rhythm, muscle tone during sleep, and airway control. This is why sleep problems in MSA often go beyond simple difficulty falling or staying asleep, and can involve the body’s basic sleep-related safety mechanisms.
Common Sleep Problems in MSA
1. REM Sleep Behaviour Disorder (RBD)
RBD acting out dreams physically, sometimes with kicking, punching, or shouting is frequently one of the earliest symptoms of MSA, often appearing years before movement symptoms develop. (For a full explanation of RBD and how it’s diagnosed, see our guides on RBD diagnosis and its connection to neurodegenerative disease.)
2. Insomnia and Fragmented Sleep
Difficulty falling or staying asleep is common and can stem from several overlapping causes night-time urinary urgency (a common autonomic symptom in MSA), muscle stiffness making it hard to find a comfortable position, or anxiety related to the condition itself.
3. Obstructive Sleep Apnea (OSA)
Standard sleep apnea, where the airway repeatedly narrows or collapses during sleep, can occur in MSA just as it does in the general population, though it may be compounded by MSA-related muscle and autonomic changes.
4. Nocturnal Stridor – Why It Needs Special Attention
This is the sleep symptom I discuss most carefully with MSA patients and families. Stridor is a harsh, high-pitched breathing sound during sleep, caused by abnormal narrowing or paralysis of the vocal cords – distinct from ordinary snoring, both in sound and in significance.
Why it matters:
- Stridor occurs due to the same nerve pathway damage affecting other automatic functions in MSA
- Research has linked early-onset stridor to a more rapidly progressing disease course
- In more severe cases, stridor can be associated with breathing difficulty during sleep that requires specific intervention
In my practice, I take any report of unusual night-time breathing sounds – particularly if a bed partner describes a harsh, strained quality different from typical snoring – seriously enough to arrange prompt evaluation, since this is one symptom where earlier recognition genuinely changes the management approach.
This is not meant to cause alarm many MSA patients with stridor are managed successfully for extended periods with the right interventions. The key point is that this specific symptom, unlike ordinary insomnia or mild sleep fragmentation, warrants a specific and timely conversation with your neurologist rather than being dismissed as “just snoring.”
How Sleep Problems in MSA Are Diagnosed
- Detailed history from both patient and bed partner – descriptions of breathing sounds, movements, and sleep quality
- Video polysomnography (overnight sleep study) – the key diagnostic tool, capable of detecting RBD, OSA, and stridor in the same study, distinguishing between them based on their distinct patterns
- ENT/laryngoscopy evaluation – sometimes used alongside polysomnography specifically to assess vocal cord function if stridor is suspected
Management Approaches
For RBD
Safety modifications to the sleeping environment, and medications such as melatonin or, in select cases, low-dose clonazepam – the same approach used for RBD in other conditions, discussed in more detail in our RBD diagnosis guide.
For Insomnia
Addressing contributing factors first – managing night-time urinary symptoms, optimizing medication timing, and standard sleep hygiene measures – before considering sleep medications, which need to be chosen carefully given MSA patients’ sensitivity to certain drug side effects.
For Obstructive Sleep Apnea
Continuous positive airway pressure (CPAP) is the standard treatment, same as for OSA in the general population.
For Nocturnal Stridor
- CPAP or BiPAP – positive airway pressure can help manage milder stridor in some patients
- Tracheostomy – reserved for more severe cases where airway obstruction poses a significant risk; this decision is made individually, weighing severity, disease stage, and the patient’s and family’s wishes
- Regular reassessment – since stridor severity and MSA’s overall course can evolve, ongoing monitoring rather than a one-time evaluation is standard practice
A Note for Caregivers
If you share a bed or bedroom with someone who has MSA, you’re often the first to notice these changes – a new breathing sound, unusual restlessness, or increasingly disrupted sleep. These observations are genuinely valuable clinical information, even if they seem minor day to day. Mentioning them specifically at appointments, rather than assuming they’re a normal part of aging or unrelated to MSA, helps your care team catch and address issues early.
If you or someone you’re caring for has MSA and is experiencing new or worsening sleep symptoms – particularly unusual breathing sounds during sleep – raising this with your neurologist is a reasonable and important step, not an overreaction.
Authoritative References
- Multiple System Atrophy Coalition – Sleep Disorders in MSA
- National library of medicine – Sleep Disturbances in Multiple System Atrophy
- National Institute of Neurological Disorders and Stroke – Multiple System Atrophy
