AAN 2026 | Guidance for the treatment of autonomic dysfunction in patients with movement disorders
Mitchell Miglis, MD, Stanford Health Care, Stanford, CA, shares guidance for the treatment of autonomic dysfunction in patients with movement disorders. Dr Miglis highlights the importance of multi-disciplinary collaboration and notes that treatment for orthostatic hypotension typically begins with non-pharmacological therapies, followed by medications like vasoconstrictors. This interview took place at the 78th American Academy of Neurology (AAN) Annual Meeting in Chicago, IL.
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Transcript
I mean, these patients can be incredibly complex and very challenging to treat. So we really do collaborate a lot with other subspecialists, primarily urologists and gastroenterologists for treatment. As neurologists, we treat a lot of the cardiovascular complications, namely the orthostatic hypotension. So for that treatment, the first step is non-pharmacological therapies, increasing fluid, increasing salt, compression, trying to get patients more physically active with exercise to kind of build up their muscle mass and prevent deconditioning...
I mean, these patients can be incredibly complex and very challenging to treat. So we really do collaborate a lot with other subspecialists, primarily urologists and gastroenterologists for treatment. As neurologists, we treat a lot of the cardiovascular complications, namely the orthostatic hypotension. So for that treatment, the first step is non-pharmacological therapies, increasing fluid, increasing salt, compression, trying to get patients more physically active with exercise to kind of build up their muscle mass and prevent deconditioning. And then if we do need medications, which most of these patients do, the first line is typically vasoconstrictors. So things like midodrine or volume expanders like fludrocortisone, droxidopa, essentially medications to sort of either expand volume or constrict the vessels. Urology is very, very important to treat, you know, neurogenic bladder that can occur. GI colleagues are very helpful for the constipation and some of the gastric motility disorders that patients have. In addition to that, a lot of patients have heat intolerance with sweating problems, typically sweating too little and then they get overheated. And that can be very challenging to treat, but sometimes we can use sort of cholinergics to kind of increase that sweat production. Yeah, so dopaminergic therapy, which is used very commonly in Parkinsonism, can decrease blood pressure. So it’s just something to keep in mind if patients are on carbidopa, levodopa, or other dopamine agonists that it will lower blood pressure. So we often will time doses of these autonomic medications, these vasoconstrictors with the dopamine therapy to try to better counterbalance that. It’s also another important point to mention is with meals. You know, a lot of these patients can have big blood pressure drops with meals, so sometimes we have to time the medication maybe 30 minutes before a meal to prevent that excessive blood pressure drop.
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