Purpose <p>Few studies have examined the association between cardiovascular autonomic failure and minor hallucinations in patients with Parkinson’s disease (PD). The aim of this study was to clarify this association.</p> Methods <p>The subjects were 133 patients with PD without well-structured visual hallucinations. Visual illusory responses were evaluated using the noise pareidolia test. Cardiac ¹²³I-metaiodobenzylguanidine (¹²³I-MIBG) uptake and neurogenic orthostatic hypotension (nOH) and supine hypertension (nSH) on head-up tilt-table testing were examined in association with the incidence of pareidolia.</p> Results <p>Fifty-one (38%) patients had pareidolia. nOH (β = 0.220, <i>p</i> = 0.008), cognitive impairment (β = −0.228, <i>p</i> = 0.028), and longer symptom duration (β = 0.273, <i>p</i> = 0.006) were associated with an increased incidence of pareidolia independently of age, sex, motor severity, levodopa-equivalent dose, and anticholinergic and cholinesterase inhibitor use. An increased incidence of pareidolia was also associated with nSH (β = 0.214, <i>p</i> = 0.009), while no such association was found with cardiac ¹²³I-MIBG uptake. Patients with severe nOH or nSH tended to have a higher incidence of pareidolia than those with mild nOH (<i>p</i> = 0.063) or nSH (<i>p</i> &lt; 0.003), respectively.</p> Conclusion <p>nOH and nSH were associated with the severity of pareidolia in early PD patients without well-structured visual hallucinations. Further studies are required to clarify whether this association is attributable to widespread central pathological changes related to cardiovascular autonomic failure, or to degeneration of the sympathetic nervous system.</p>