Restless Legs Syndrome (RLS)

Restless legs syndrome (RLS), also known as Willis-Ekbom disease, is a chronic condition that causes strong, unpleasant feelings in the legs, resulting in an overwhelming need to move them. Moving the legs relieves the unpleasant sensations. 1 2

RLS is considered a condition of the nervous system, sometimes referred to as a neurological disorder. Because RLS can seriously affect some people’s sleep patterns, it can also be classed as a sleep disorder. 3

Around eight percent of the population of the U.S. 4 is thought to be affected by RLS. Symptoms often begin at around 40 to 45 years of age, more often affecting women than men. This is known as late-onset restless legs syndrome.

Early-onset restless legs syndrome is when the condition appears before the age of 45, with symptoms rarely starting as early as during childhood. Early-onset restless legs syndrome appears to be more likely to run in families than the late-onset version of the condition.

People affected by other conditions, such as iron deficiency anemia 1 or Parkinson’s disease 5 may also show symptoms of restless legs syndrome. These symptoms can also sometimes appear during pregnancy.

Restless legs syndrome cannot be cured. However, various treatments, including home remedies, lifestyle changes, and natural treatments, can lessen the severity of symptoms. If RLS is triggered by a specific condition or medication, treating that condition can eliminate RLS.

The main symptom of RLS is an overwhelming urge to move the legs because of uncomfortable and unpleasant feelings in one or both legs.

The sensations in the legs and, in severe cases, the arms are variously described as: 1 7 8

• Crawling
• Itching
• Aching
• Throbbing
• Pulling
• Burning
• Painful
• Fizzing
• Tickling
• Tingling
• Feeling the urge to move
• Cramping
• Restlessness
• Creeping
• Causing discomfort
• Tenseness
• Having an electric current

Some people may experience the feelings as painful, but most people feel the sensations as an ache rather than a sharp or sudden pain.

Symptoms occur when the person is at rest or inactive, such as: 4 7

• Lying down
• Sitting
• In bed
• In a restricted space, like on a plane or at the movies

As a person is more likely to be at rest in the afternoon and evening, those are the parts of the day when RLS symptoms are usually at their worst. For some of those affected by RLS, the symptoms may only occur occasionally, while for others they are present every day.

Symptoms tend to improve in the mornings with getting up, and whenever the person starts to move or walk around. 1 Moving around as a remedy can cause problems when the person is trying to go to sleep.

Symptoms can vary in severity, from mild discomfort to being so disruptive and painful they affect day-to-day life. Sleep can be so disturbed that people have difficulty functioning during the day, which can commonly lead to depression and anxiety. 1 9 8

Periodic limb movement in sleep (PLMS), also known as periodic limb movement disorder (PLMD) 2, is experienced by about 80 percent of people with restless legs syndrome. 10

Periodic limb movement in sleep causes limbs, commonly the legs but also sometimes the arms, to jerk or twitch involuntarily during sleep. It can be so severe as to wake the sleeper and disturb anyone sharing the bed. Involuntary limb movements may also occur during waking hours, when it is known as periodic limb movement during awakening (PLMW or PLMA). 10

Most people with restless legs syndrome have PLMS, but many people with PLMS do not also have restless legs syndrome.

In most cases, it is not known what causes restless legs syndrome . This is called primary, or idiopathic, RLS.

Sometimes restless legs syndrome is caused by another health condition. This is known as secondary RLS.

Primary restless legs syndrome tends to begin slowly, around the age of 40. This is earlier than most secondary RLS cases. RLS also runs in families, suggesting a genetic link. 9 11

There is research that suggests restless legs syndrome may be connected to problems with a part of the brain called the basal ganglia, which uses dopamine to control muscle movement. If transmission of dopamine signals in this part of the brain becomes impaired, it can result in muscle spasms and jerky movements. 1

There are a number of factors that appear to be linked to restless legs syndrome. These may include:

A lack of iron in the body, leading to iron deficiency anemia 12, appears to be linked to restless legs syndrome. 13 Iron plays a role in the functioning of dopamine and other neurotransmitters’ function in the brain.

Read more about iron deficiency anemia »

Pregnant women may develop restless legs syndrome, with symptoms more common in the final trimester. Between 10 percent and 25 percent of pregnant women are thought to experience symptoms. 14

Nobody is quite sure why pregnancy can trigger restless legs syndrome. There are suggestions it may be connected to: 14

• Low iron levels
• Low folate levels
• Circulation problems
• Increase in estrogen

Restless legs syndrome that develops during pregnancy very often goes away within a month after birth. 1

There are several conditions that can lead to restless legs syndrome as a complication, or have been linked to it, sometimes without yet fully understanding the mechanisms behind the link, such as: 11 8

• End-stage kidney disease, particularly when needing dialysis
• Nerve damage. This includes peripheral neuropathy, which may itself be a complication caused by diabetes
• Spinal cord disease
• Multiple sclerosis
• Fibromyalgia
• Parkinson’s disease
• Rheumatoid arthritis

Many medications and other substances can make restless legs syndrome worse, or rarer even cause it, these include such as: 11

• Certain antidepressants, including selective serotonin reuptake inhibitors (SSRIs), Serotonin-norepinephrine reuptake inhibitors (SNRIs), and tricyclic antidepressants (TCAs)
• Metoclopramide, an anti-nausea medication
• Certain antipsychotic medications, such as haloperidol and phenothiazines
• Lithium is used to treat bipolar disorder or sometimes for severe depression
• Diphenhydramine, an antihistamine, found in cold and allergy medications
• Calcium channel blockers, used to treat high blood pressure
• Beta-blockers, used to treat blood pressure and heart conditions
• Caffeine and alcohol
• Smoking tobacco

These are the diagnostic criteria for RLS, published by the International Restless Legs Syndrome Study Group (IRLSSG). All five criteria are required for the diagnosis: 8

An urge to move the legs, usually caused by uncomfortable and unpleasant sensations in the legs. Sometimes the urge to move is present without the sensations, and sometimes the arms or other body parts are involved as well as the legs.

The urge to move or sensations in the limbs begin or become worse while resting.

The urge to move or sensations in the limbs are partially or totally eased by moving. Relief lasts as long as the movement continues.

The urge to move or sensations in the limbs are worse in the evening or night or only happen in the evening or night.

Symptoms are not explained by another medical or behavioral condition.

Check whether this matches your symptoms with the Ada app.

A doctor will diagnose based on a description of symptoms and triggers. A physical and/or neurological exam may be done, a family history taken, and possibly blood tests to look for underlying factors or other treatable conditions.

A sleep study may be helpful to check for sleep disruption and periodic limb movement in sleep.

The Restless Legs Syndrome Foundation 4 produces an RLS Symptom Diary 15 which can be printed off and used to track symptoms, activities, and sleep patterns. RLS-UK also has a tool to help affected people monitor symptoms and medication. 16

There is thought to be a genetic link with restless legs syndrome, especially with primary restless legs syndrome . The Restless Legs Syndrome Foundation reports that 35 percent of people with the condition say they first experienced symptoms before the age of 20, and that 1.5 million children and adolescents in the United States are believed to be affected. 17

Children with RLS are likely to be tired during the day, due to disturbed sleep. This can affect their performance in school, social functioning and interactions with peers and family.

RLS is usually diagnosed based on a person’s description of their symptoms. However, it can be difficult for children to express what they are experiencing and accurately report their symptom history. Children exhibiting twitching and fidgeting may be mistaken for having ADHD. There is research to suggest 25 percent of children with RLS or periodic limb movements in sleep may be misdiagnosed as having ADHD. 18

There is often no cure for primary restless legs syndrome, though its symptoms can be managed to make the condition easier to live with.

If restless legs syndrome is caused by a condition or medication, symptoms may go away and not return if the condition is cured or the causative medication is stopped. For example:

• RLS caused by pregnancy typically ends within four weeks after giving birth
• Treating iron deficiency with iron supplements may cause an associated RLS to go away
• RLS caused or made worse by a medication may be treated by stopping or changing medication, after consultation with a medical professional

Where restless legs syndrome is thought to be caused by an iron deficiency anemia, a lack of iron and/or ferritin in the body, treatment with iron supplements is advised.

A blood test, physical examination, and discussion with a doctor will establish the appropriate amount of iron supplements per day, possibly taken alongside supplements of vitamin C to help absorption. If this does not affect iron levels, less commonly, an intravenous infusion may be necessary. 1 7

Side effects of taking more than 20mg of iron a day can include: 19

• Constipation
• Stomach ache
• Nausea and vomiting

Taking extremely high doses of iron can be dangerous. Although iron supplements are commonly available, treating restless legs syndrome with iron should be supervised by a medical professional.

If the symptoms of restless legs syndrome are mild, lifestyle changes may be the only treatment needed. In these cases, there are plenty of natural treatments and home remedies that can be tried. 1 20

Adopting good sleep practices can help a person with restless legs syndrome get enough sleep. Not getting enough sleep can be one of the most disruptive consequences of RLS. Good sleep habits can include:

• Going to bed and waking up at regular times, even on the weekends or days off
• Not napping during the day
• Make sure the bedroom is dark, cool, quiet, and comfortable
• Taking electronic equipment, such as TV and phone, out of the bedroom

Changes to diet may also help with reducing symptoms of restless legs syndrome:

• Avoid stimulants, like caffeine, nicotine, and alcohol, particularly before bed
• Drink plenty of water to prevent dehydration

Certain activities can ease restless legs syndrome symptoms, such as: 20

• Regular, moderate exercise
• Avoid being confined in places, for example, choose an aisle seat at the movies or on a plane
• Massaging the legs
• Taking a warm bath
• RLS-UK suggests hot-cold therapy, a shower of alternating hot and cold water
• Simple leg stretches or getting up and walking a little as often as possible may help in confined spaces like a plane, as well as in daily life when e.g. working a desk job sitting all-day

The U.S. Food and Drug Administration has approved devices to treat restless legs syndrome 1, including a foot wrap 21 and a vibrating pad. This pad, called Relaxis®, has been found to improve quality of sleep. 22

In more severe cases of RLS or when other treatments do not improve symptoms sufficiently, a medical professional may recommend medication for the condition.

A class of drugs called dopamine agonists works by mimicking dopamine in the brain to stimulate a response. They are also often used to treat Parkinson’s disease. 23

Multiple types of dopamine agonists have been approved to treat restless legs syndrome, among them: 1

• Bromocriptine
• Ropinirole
• Pramipexole
• Rotigotine, taken as a skin patch

Side effects of these drugs can include:

• Nausea
• Sleepiness
• Headaches
• Dizziness
• Fainting when standing up

Levodopa is a drug that the body converts into dopamine. It is usually taken alongside a drug called carbidopa, which stops levodopa from being converted into dopamine before reaching the brain. 24 25

Sudden drowsiness and falling asleep can be a side effect of taking levodopa. It is advisable not to drive, operate machinery, or take part in potentially dangerous activities until it’s clear how levodopa affects the person taking it. 25

Levodopa is not recommended for long-term use as it can make restless legs syndrome symptoms worse. It’s generally prescribed for occasional, short-term use, e.g. when people feel symptoms coming on.

The U.S. Food and Drug Administration (FDA) has approved gabapentin enacarbil for treating restless legs syndrome. Two other anti-seizure medications, pregabalin and gabapentin, are being trialed, but not currently approved by the FDA for RLS treatment. 7

A long-release form of gabapentin enacarbil is used to treat restless legs syndrome. The medication decreases the uncomfortable, creeping feelings in the legs. 1 26

Possible side effects, which lessen over time, of gabapentin enacarbil include: 26

• Fatigue is a strong physical tiredness
• Feeling dizzy
• Feeling sleepy

Gabapentin enacarbil appears to be as effective or better at treating symptoms of restless legs syndrome as the dopamine agonist pramipexole. It seems to be of particular benefit to people with RLS, who are: 7 8

• In pain
• Experiencing disturbed sleep as the primary symptom
• Having difficulty with impulse control

One of the most disruptive effects of restless legs syndrome can be lack of sleep. Medication from the benzodiazepine class of drugs, also known as hypnotics, may be prescribed as a short-term solution to help induce sleep. Benzodiazepines can include: 1 7

• Temazepam
• Clonazepam
• Lorazepam
• Zaleplon
• Eszopiclone

These drugs are not recommended for long-term use because of their various side effects, which include: 1

• Feeling sleepy during the day
• Lack of concentration
• Feeling sluggish
• Causing or worsening sleep apnea
• High risk of addiction

There are complications associated with dopamine medication used for treating restless legs syndrome.

Augmentation is the name for symptoms worsening under long-term use of certain medications for restless legs syndrome. People experiencing augmentation often find that symptoms start earlier in the day, start quicker once they rest, and the symptoms become more severe or spread further than previously. 7

Augmentation is more common with long-term levodopa use, seen in possibly up to 80 percent of cases as opposed to longer-term dopamine agonist use, where this is generally seen in less than 30 percent of cases. It tends to occur around six months after starting a particular treatment. 27

Ending the treatment will likely relieve signs of augmentation. However, coming off the drugs may be difficult as withdrawal symptoms can occur.

Good to know: To date, gabapentin enacarbil, an alternative to dopamine medication, has not been shown to cause augmentation. 7

Rebound occurs when restless legs syndrome symptoms appear in the morning or late at night and are related to a dose of the drug wearing off. It is differentiated from augmentation by lacking a worsening in severity of symptoms and of symptoms recurring at a different time of day; rebound often occurs in the morning as opposed to during the evening, as seen in augmentation. 27

As with augmentation, rebound can be halted and reversed by stopping taking the medication. Rebound can also be counteracted with longer-acting medication formulations.

The US Food and Drug Administration has not approved any medication for treating restless legs syndrome in children. The long-term effects of treating children with medication approved for adults are unknown. 28

Benzodiazepines, such as clonazepam, are not recommended for children because they can increase the risk of collapse of the upper airway. Up to 20 percent of children taking levodopa and carbidopa develop a side effect of feeling nauseous. 28

Good sleep habits are recommended for treating restless legs syndrome in children, as is avoiding caffeine and antihistamines. Vitamin and mineral supplements may help when taken in consultation with a doctor. 18 28

Q: Is restless legs syndrome painful?
A: Not generally. People tend to describe the sensations caused by restless legs syndrome as uncomfortable, such as feelings of crawling or itching. In severe cases, people may report feeling pain.

Q: Does restless legs syndrome get worse with age?
A: Primary restless legs syndrome has no cure. Although symptoms may worsen with age, treatment and therapy can bring symptoms under control and minimize disruption to everyday life. 1

Q: What vitamins help restless leg syndrome?
A: Sometimes restless legs syndrome is caused by an iron deficiency, in which case iron supplements can ease or reverse symptoms. If a person has a healthy and balanced diet, there is usually no need for supplements. A medical professional can assess whether symptoms of RLS are caused by a vitamin or mineral deficiency and can recommend supplements where necessary.

Q: Does magnesium help restless legs syndrome?
A: Although some people with restless legs syndrome report that products like magnesium oil spray have been helpful, and others report magnesium supplements helped with insomnia, 29 30, Harvard Men’s Health Watch notes that studies on magnesium and sleep have, to date, been small and of short duration. 31 A well-grounded scientific basis for using magnesium to help with restless legs syndrome is currently lacking.

Q: What essential oils help with restless legs syndrome?
A: Although some people report that symptoms are reduced by using essential oils, there is no scientific evidence that they have any effect. Any benefit is likely to be from massaging the legs or the placebo effect.

Q: What home remedies and natural treatments work for restless legs syndrome?
A: There are some lifestyle changes, such as good sleep hygiene, avoiding stimulants and taking exercise, that can ease symptoms of restless legs syndrome. There are reports that drinking quinine tonic water, or placing a bar of soap under a bed sheet at night, will help; however, there is no scientific evidence for these activities, and any benefit is likely to be the placebo effect.

Q: What causes restless legs syndrome?
A: Nobody quite knows what causes primary restless legs syndrome. In some cases, restless legs syndrome can appear as a secondary condition, such as when someone is pregnant, has end-stage renal disease, or has an iron deficiency.

Q: What’s the best treatment for restless legs syndrome?
A: The best way to treat restless legs syndrome will depend on whether a cause can be found and how severe the symptoms are. For example, if RLS is being caused by an iron deficiency, the treatment will be to take iron supplements. If a person has primary RLS, but symptoms are mild, they may be able to manage them without medication. If symptoms are severe, there are various medications. A doctor can help to find the appropriate treatment.

Q: Will my restless legs syndrome develop into Parkinson’s disease?
A: Restless legs syndrome will not develop into another neurological disorder, such as Parkinson’s disease. However, there may be serious complications of long-term sleep deprivation, which can include developing depression, anxiety, and a higher risk for diabetes.

Q: Can you have restless legs syndrome in your arms?
A: Yes. In severe cases of restless legs syndrome, symptoms can affect the arms, face, and trunk of the body.

Q: What exercises can I do for restless legs syndrome?
A; Regular, moderate exercise has been shown to lower the severity of restless legs syndrome symptoms. 11 Walking and stretching have also shown benefits, particularly a non-strenuous walk in the evening.