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For most people, bedtime promises a welcome break from the day but not for people with restless legs syndrome. When they lie down, a crawling tingling or burning will begin in one or both legs along with an irresistible impulse to move. Pretty soon, they’re up on their feet walking, stretching—anything to get rid of the feeling. It’s a nighttime ritual millions of Americans suffer from every night but for many it can be resolved.. A visit to a healthcare professional can start them on the road to resolution.
Restless legs syndrome (RLS), or Willis-Ekbom Disease, is a common and complex disorder characterized by an irresistible urge to move the legs, an urge often accompanied by unpleasant and abnormal sensations deep in the leg tissues such as itching, tingling, or crawling. The urge usually manifests at night or during long periods of sitting, such as driving or watching TV. Walking, stretching, moving around—all these help relieve both the urge and the sensations.
Because the symptoms worsen or only occur at night, RLS is often classified as a sleep disorder. In fact, RLS is a leading cause of insomnia. Because the urge to move the legs usually starts at night, people with RLS find it difficult to fall or stay asleep. Many also have Periodic Limb Movement Disorder (PLMD), a condition in which the legs periodically cramp and jerk around during sleep. Lack of sleep and daytime sleepiness are common experiences for people with RLS.
In the United States, three million people each year are diagnosed with restless legs syndrome (RLS), but healthcare professionals all agree that the condition is significantly underdiagnosed. The best guess is that anywhere from 5-10% of Americans have RLS. Many cases are mild and/or intermittent, but more severe and chronic cases can substantially reduce a person’s quality of life, leading to depression and even suicide.
RLS can be a temporary condition caused by some other problem. Secondary restless legs syndrome can often be resolved by correcting the underlying problem. Iron deficiency, folate deficiency, magnesium deficiency, pregnancy, nerve pain, diabetes, fibromyalgia, celiac disease, and end-stage kidney disease can all cause RLS. Some medications produce RLS as a side effect, or worsen symptoms if already present. These include classes of antidepressants known as TCAs and SSRIs, medications which block dopamine—including many antipsychotics, and even some antihistamines. Alcohol, caffeine, and products containing nicotine have been known to worsen symptoms.
Some RLS cases have no identified cause. Called primary restless legs syndrome, or familial restless legs syndrome, the condition is chronic and probably inherited. It usually starts intermittently in childhood or early adulthood but the diagnosis isn’t made until much later as symptoms become more of a daily occurrence. Some may develop primary RLS later in life with more of a rapid onset and progression of symptoms.
RLS is universally considered a problem with the nervous system. Scientists have not quite pinned down the exact cause, but the most likely culprit in primary and some secondary RLS cases is dysfunction of the section of the brain that uses dopamine to conduct purposeful muscle movement. We know that other movement disorders like Parkinson’s disease, which result in involuntary movements, also occur because of a disorder in dopamine pathways.
The good news is that most cases of RLS are treatable. Many RLS symptoms caused by an underlying condition can be resolved. More severe cases of primary or familial RLS can be managed with neurological medication but unfortunately no cure exists.
Restless legs syndrome is usually diagnosed from the symptoms. A physical exam and testing are only used to rule out other conditions.
Most patients will first bring the problem to a family practitioner, but RLS is definitively diagnosed and treated by specialists including neurologists, psychiatrists, and sleep specialists.
There are five symptoms required for a diagnosis of RLS:
A medical history will help determine whether the condition is primary or secondary. The doctor will look for risk factors such as:
Family history strongly indicates the condition may be inherited. If other conditions are present, a healthcare provider may start by addressing those problems first.
The physical exam usually turns up normal results. The physician, however, will be looking for signs of other neurological conditions, such as Parkinson’s disease or a compressed spinal nerve (radiculopathy), that might be causing the symptoms.
There are no specific tests to diagnose RLS, but a physician will order tests to rule out other conditions or discover a possible cause for the RLS. The physician will order blood tests to measure serum ferritin (iron), magnesium, or folate levels, since deficiencies in any of these nutrients can cause RLS. Other substances in the blood might point to other causes such as diabetes or kidney problems. Nerve tests, such as a nerve conduction study or an electromyogram, may be performed to rule out other neurological disorders.
Finally, RLS patients with severe sleep disturbances or who have periodic leg movements during sleep may be referred to a sleep clinic. They will spend a night undergoing a polysomnogram—a sleep study. This test will quantify the person’s sleep patterns as well as how much the legs are moving during sleep, and can also be used to identify other underlying or contributing conditions.
There are several treatment options for restless legs syndrome, including lifestyle changes, dietary supplements, over-the-counter pain relievers, medical devices, and powerful neurological medications.
For secondary RLS, the treatment of choice is to manage the underlying condition causing the problem.
Many RLS patients may be given dietary supplements of iron, magnesium, or folate to reduce symptoms. Iron, in particular, is vital to the body’s production of dopamine, so iron supplementation is a common treatment for RLS.
If RLS is medication-related, the person will be taken off that medication. And, finally, patients with kidney failure may be givenshort daily dialysis sessions to help reduce RLS symptoms.
RLS that occurs during pregnancy often resolves within four weeks after delivery.
RLS symptoms can be minimized by lifestyle changes including avoiding caffeine, alcohol, and nicotine-containing products;exercising, stretching, self-massage, and good sleep hygiene. Mild RLS symptoms can be effectively controlled with over-the-counter pain relievers such as ibuprofen or acetaminophen.
RLS symptoms are believed to be generated by the brain because of a shortage of dopamine, a chemical that transmits signals between nerves to conduct purposeful movement. First-line treatment of chronic moderate-to-severe RLS consists of drugs that act like dopamine, called dopamine agonists, or by gabapentinoids, a type of anticonvulsant drug often used to relieve nerve pain. Patients who do not get results can be treated with low-dose opioids.
Physical therapy devices can provide sufficient symptom relief to help people sleep at night, mostly through “counter-stimulation,” that is, creating sensations, such as vibrations, that “drown out” RLS sensations generated by the brain. These include vibrating pads (Relaxis), pneumatic compression sleeves, foot wraps (Restiffic), heating pads, and icing.
Medications are usually not required for mild or secondary restless legs syndrome other than supplements or OTC pain relievers. First-line treatments for chronic or severe RLS are dopamine agonists or gabapentinoids, anti-seizure drugs that can also relieve nerve pain. When all else fails, low doses of opioids can manage symptoms.
RLS is believed to be primarily caused by a shortage of dopamine in the brain. Dopamine agonists (or dopaminergics) such as pramipexole, ropinirole, cabergoline, and rotigotine, are drugs that “mimic” dopamine in the brain. They are remarkably effective at reducing RLS symptoms and dramatically improve sleep. After a while, however, they will lose effectiveness and often worsen RLS symptoms, a phenomenon known as “augmentation.” Because of the risk of augmentation, dopamine agonists are prescribed for RLS at the lowest possible dose for the shortest period.
Gabapentinoids were originally developed as anti-seizure (anticonvulsant) medications, but are now widely used to relieve pain. These drugs reduce the excitability of nerves in the spinal cord, effectively “quieting” RLS symptoms as well as other kinds of nerve pain. They do notrisk worsening RLS symptoms in the same way as dopamine agonists. For this reason, healthcare professionals are increasingly turning to gabapentinoids—Horizant (gabapentin enacarbil), Lyrica (pregabalin), and a generic formulation gabapentin, as first-line therapy to treat severe or chronic RLS.
Low potency opioids like tramadol and hydrocodone, can be effective for treating intermittent cases of RLS symptoms on an as needed basis. For moderate to severe cases that cannot be successfully treated with dopamine agonists or gabapentinoids, the second line treatments are more potent opioids. These may be added on to other drug classes or used as monotherapy. Oxycodone and methadone are particularly effective at relieving RLS and improving sleep in situations of extreme symptoms, especially if a patient must be abruptly taken off a dopamine agonist. These medications also come with unique challenges for long-term use and generally the lowest doses possible should be used.
Medications which include levodopa (a molecule the body converts into dopamine) and benzodiazepines, such as clonazepam, were prescribed for RLS to treat symptoms or put patients to sleep. They are, however, rarely prescribed these days. Levodopa rapidly loses effectiveness and causes augmentation, and benzodiazepines have a high potential for abuse.
People with mild RLS can manage nighttime symptoms acetaaminophen, or with NSAIDs (nonsteroidal anti-inflammatory drugs) such as aspirin and ibuprofen.
Most patients with RLS will be prescribed or advised to take an iron supplement. Iron is a critical component in the body’s production of dopamine. Magnesium or folate (vitamin B9) deficiency can also cause RLS, so supplements may be advised or prescribed.
Restless legs syndrome is a complex neurological condition. Some of the most effective medications, dopamine agonists, lose effectiveness very quickly and could make the condition worse over time. Others have serious side effects. Many of the medications prescribed by doctors are not approved for RLS, so their effectiveness has not been proven. For all these reasons, the “best” medication for restless legs syndrome will depend on how well the patient responds to any therapy.
| Best medications for restless leg syndrome | |||||
|---|---|---|---|---|---|
| Drug Name | Drug Class | Administration Route | Standard Dosage | Common Side Effects | |
| Requip (ropinirole) | Dopamine agonist | Oral | Lowest dose possible, starting at 0.25 mg once daily taken three hours before bedtime | Nausea, sleepiness, compulsive behaviours | |
| Mirapex (pramipexole) | Dopamine agonist | Oral | Lowest dose possible, starting at 0.125 mg once daily taken three hours before bedtime | Nausea, sleepiness, compulsive behaviors | |
| Neupro (rotigotine) | Dopamine agonist | Transdermal patch | Lowest dose possible, starting at 1 mg/24 hours | Nausea, sleepiness, compulsive behaviors | |
| Dostinex (cabergoline) | Dopamine agonist | Oral | Lowest dose possible, starting at 0.5 mg once daily taken three hours before bedtime | Headache, nausea, dizziness | |
| Horizant (gabapentin enacarbil) | Gabapentinoid | Oral | 600 mg taken at 5 pm daily | Dizziness, sleepiness, headache | |
| Lyrica (pregabalin) | Gabapentinoid | Oral | 50 mg to 75 mg once daily taken three hours before bedtime | Headache, dry mouth, nausea | |
| OxyContin (oxycodone) | Opioid | Oral | Lowest dose possible, 5mg to 15mg taken every four to six hours | Constipation, nausea, sleepiness | |
| Motrin (ibuprofen) | NSAID | Oral | 200 mg to 400 mg taken every four to six hours as needed | Nausea, bleeding, stomach pain | |
| Tylenol (acetaminophen) | Pain reliever | Oral | 325 mg to 650 mg every six hours as needed | Nausea, stomach pain, loss of appetite |
Many of the standard dosages above are from the U.S. Food and Drug Administration (FDA) and the National Institutes of Health (NIH). Suggested opioid doses are from the Mayo Clinic and the American Academy of Neurology. Dosage is determined by your doctor based on your medical condition, response to treatment, age, and weight. Other possible side effects exist. This is not a complete list.
All medications may have side effects, and different classes of medications have different side effects. However, this is not a complete list, and you should consult with your healthcare professional for possible side effects and drug interactions based on your specific situation.
Prescription dopamine agonists, gabapentinoids, and opioids all cause sleepiness, fatigue, confusion, and dizziness as common side effects.
Some severe side effects of dopamine agonists are hallucinations and serious impulse control problems, such as overeating or gambling recklessly. However, the most common serious side effects of dopamine agonists are augmentation and withdrawal.
Augmentation means dopamine agonists will eventually make RLS symptoms worse if the drug is taken long enough. This is not the same as developing drug tolerance. Instead, the drug worsens the underlying condition. Symptoms revert to baseline when the drug is discontinued.
Dopamine agonists have a high risk of withdrawal, called dopamine agonist withdrawal syndrome (DAWS). Even when the drug is tapered, one out of five patients will experience psychiatric symptoms, such as anxiety, panic attacks, and suicidal thoughts, as well as physical symptoms, including pain, nausea, and drug cravings.
The most serious side effects of gabapentinoids and opioids are drug abuse and overdose. An overdose of either drug can be fatal, but gabapentinoids, unlike opioids, do not have an antidote.
Pain relievers such as over-the-counter NSAIDs (nonsteroidal anti-inflammatory drugs) and acetaminophen are widely available and safe. NSAIDs, unlike acetaminophen, interfere with blood clotting, so their most serious side effects are bruising and bleeding, which may present in the digestive system.
Lifestyle changes are a critical part of RLS treatment. The most effective treatments involve avoiding substances such as caffeine, alcohol, nicotine, and certain medications, that make symptoms worse. These substances have been shown to worsen the symptoms of RLS, so the first step in managing RLS is to steer clear of them. Certain antihistamines are also a bad idea.
Moderate exercise may help relieve mild RLS symptoms in some patients. Heavy workouts, however, will make symptoms worse, so don’t overdo it.
About three in four RLS patients have problems sleeping. Good sleep hygiene may not affect RLS symptoms but can improve sleep and increase daytime wakefulness. Go to bed at the same time every night, turn off the light, and eliminate distractions. Use yoga, stretching, or warm baths to relax before bedtime. Avoid heavy meals, excitement, or stimulants like caffeine before bedtime.
Massage may help relieve RLS symptoms. Try massaging the calf or the hamstrings with a massage roller. Although the evidence is unclear, massage at least can’t hurt.
Bananas do not help treat restless legs syndrome or relieve its symptoms.
Once the symptoms start, people with RLS typically can immediately reduce the symptoms by moving or stretching their legs. People with mild RLS symptoms can also get relief by using over-the-counter pain relievers such as ibuprofen or acetaminophen.
To improve sleep, people with restless legs syndrome need to make a few lifestyle changes that include avoiding alcohol, nicotine, and caffeine, practicing good sleep hygiene, relaxing before bed with a warm bath or stretching, moderate daily exercise, and leg massage. People with severe RLS will need prescription medications to reduce symptoms sufficiently to be able to sleep.
There are no specific tests for restless legs syndrome. Healthcare providers will use tests, such as blood tests or nerve conduction tests, to rule out other conditions or find a possible cause.
Restless legs syndrome can be caused by other conditions that, when successfully treated, may completely resolve the RLS. These include iron deficiency, folate deficiency, magnesium deficiency, anemia, pregnancy, neuropathy, diabetes, fibromyalgia, amyloidosis, celiac disease, venous insufficiency, and end-stage kidney disease.
RLS symptoms are typically triggered by inactivity, either by lying down to sleep at night or sitting for a long time, such as watching TV or driving.
Lifestyle changes are a key component of RLS treatment. Of the recommended home remedies, the most effective is eliminating habits that worsen symptoms. These include avoiding caffeine or alcohol, nicotine-containing products, and using certain antihistamines. Other remedies, such as exercise, massage, and maintaining good sleep hygiene may help some people, but not all.
People with mild RLS can relieve RLS symptoms with over-the-counter pain relievers such as aspirin, ibuprofen, or acetaminophen.
Many types of medications cause restless legs syndrome or make the symptoms worse. In some cases, stopping the medication is often enough to end RLS symptoms entirely. These medications include:
There is no scientific evidence that foods trigger restless legs syndrome. Caffeine and alcohol can make symptoms both more likely and more severe, and some people with RLS report that sugar does the same. Healthcare providers advise patients to avoid these substances. Otherwise, RLS symptoms are triggered by several minutes of inactivity such as sitting or lying down.
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