Kashihar et al. 1 retrospectively reviewed 252 consecutive Japanese patients with Parkinson's disease (PD) diagnosed according to the criteria of the United Kingdom Brain Bank. In total, 6% of the patients showed antecollis. The diagnosis was based on neck flexion to a variable degree and patients' complaints of difficulty in performing daily activities due to restricted visual field. There was no neuropathological validation. It is widely held that a flexed posture is a characteristic feature of PD, and antecollis may also appear, albeit rarely marked ("disproportionate antecollis"). Since the seminal description by Niall Quinn on disproportionate antecollis as a warning sign (ref flag) for multiple system atrophy (MSA) in 1989, 2 a number of reports or case series emerged corroborating the initial observation. [3][4][5][6] A retrospective comparative study of early features in MSA versus PD showed that half of the MSA and none of the PD patients exhibited antecollis of variable severity, ranging from a tendency to keep the head forward to a complete chin-onchest attitude. 4 Moreover, Askmark et al. reported that, of 459 Swedish patients with parkinsonism, seven showed antecollis and autonomic dysfunction, and six responded poorly to levodopa making a diagnosis of MSA probable. 6 Previous clinicopathological retrospective studies reported frequencies of antecollis up to 9% in MSA. [7][8][9] Although prospective comparative studies remain to be performed, available data suggest that disproportionate antecollis, although rarely occurring in PD, remains a warning sign of MSA and its presence should therefore lead to a thorough diagnostic work-up including neuroimaging and autonomic functions tests.