The first description of restless legs associated with severe sleep disturbances was written by the English physician Sir Thomas Willis (1621-1675). Although we now know more about the features and treatment of this condition, in many cases the cause of this condition remains elusive.

Who gets it?

Restless legs syndrome (RLS) can occur in 2 forms: primary (no cause is known), and secondary (associated with other medical conditions or medications). Secondary causes of restless legs syndrome include:

  • medical conditions such as kidney failure, diabetes, nerve damage, anemia, vitamin B12 deficiency, rheumatoid disease, and Parkinson's disease
  • pregnancy

Drugs such as antidepressants, cold medications, anti-nausea medications, and alcohol can aggravate the symptoms.

Restless legs syndrome affects between 5% and 15% of the population. Both men and women can have the syndrome, but women are affected more than men and it is more common in middle and older age. Children can also suffer from restless legs syndrome but children have a hard time describing their symptoms and it can be misdiagnosed as attention deficit hyperactivity disorder (ADHD). Also, during the last few months of pregnancy women are at a higher risk for restless legs syndrome, but symptoms usually resolve within a few weeks after delivery. There may be a genetic link to restless legs syndrome when symptoms appear at an earlier age.

Main features of restless legs syndrome

The main feature of restless legs syndrome is the presence of troublesome, but usually not painful, sensations in the legs that produce an irresistible urge to move. It is often difficult to describe these sensations, but terms such as creeping, burning, itching, pulling, aching, or tugging are frequently used. Sometimes people experience sharp "pins and needles" or numb feelings as well. Children often describe symptoms similar to "growing pains."

The symptoms occur or worsen at rest, typically ease with movement, and yet frequently return again upon resting. Finally, symptoms of this syndrome are worse in the evening and at night, especially when lying down. Symptoms can also come on when you are sitting for a long time such as when travelling by car or plane or when at a movie. Restlessness, fidgeting or nervousness create movements of the toes, feet, or legs when the sitting or lying down.

People with restless legs syndrome have difficulty in both getting to sleep and staying asleep. Problems in getting to sleep are due to the discomfort and the need to move, which delays the onset of sleep. About eight out of every 10 people with restless legs syndrome also have periodic limb movements of sleep (PLMS). Periodic limb movements are jerks that typically occur every 20 to 40 seconds, on and off throughout the night, which disturb sleep and the bed partner. People with periodic limb movements are usually unaware of their own movements or of the brief awakenings that disrupt sleep. Although most people with restless legs syndrome have periodic limb movements of sleep, most people with these nighttime limb movements, especially seniors, do not have any other features of restless legs syndrome.

Because of difficulty sleeping, people with restless legs syndrome may be abnormally tired or even sleepy during waking hours. Chronic sleep deprivation and its effects on alertness, mood and thinking can affect work, relationships, and recreational activities. Unfortunately, the symptoms of RSL usually worsen over time.

Assessment for restless legs syndrome

Before undertaking any treatment for restless legs syndrome, you should have a complete medical assessment, including a detailed medical history, physical examination, selected laboratory tests, and usually an evaluation in a sleep laboratory. A careful medical evaluation is required to distinguish between primary and the secondary forms of restless legs syndrome, since secondary forms are treated by treating the underlying cause. For example, 25% to 30% of people with restless legs syndrome are deficient in iron, and should be put on iron supplements to see if symptoms improve.

A diagnosis of restless legs syndrome is made if you:

  • feel the need to move your legs because of unpleasant feelings in your legs
  • your symptoms get worse when you are resting or not moving a lot
  • your symptoms improve or go away when you move
  • your symptoms are worse at night or only happen at night

Devising a treatment strategy

The best treatment plan for restless legs syndrome requires working closely with your doctor. As outlined below, choosing a healthy lifestyle and eliminating symptom-producing substances will all help reduce or eliminate the need for medications. However, if medications are required, you may need to try more than one medication to find the best one at the right dosage for you.

Lifestyle changes to ease the symptoms

Simple lifestyle changes can lessen the symptoms of restless legs syndrome. As caffeine can worsen symptoms, drinking coffee, tea, and soft drinks containing caffeine and eating chocolate should be reduced or stopped altogether. Also, since the consumption of alcohol and the use of tobacco products increase the duration or intensity of symptoms you should also reduce or eliminate them.

Fatigue and drowsiness tend to worsen symptoms. Therefore, having good sleep hygiene is often helpful to feel well rested and, over time, reduce symptoms. Sleep hygiene includes ensuring that the sleeping environment is comfortably cool (or warm) and quiet, going to bed at the same time every night, and getting up at the same time every morning. For more information about sleep hygiene, read our article about it.

A variety of activities also provide effective, although temporary, relief: walking, stretching, taking a hot bath, massaging the affected limb, and applying hot or cold packs. When movement is impossible or restricted, as when travelling, distracting activities can be helpful, such as reading a gripping novel, performing intricate needlework, or playing video games.

Drug treatment

Unfortunately, most people with restless legs syndrome eventually require medications to provide relief.

Dopamine agonists are the treatment of choice for chronic restless legs syndrome. These medications, such as pramipexole and ropinirole, work by mimicking dopamine, a chemical that the body naturally produces that regulates the delivery of messages between cells in the nervous system.

Although carbidopa-levodopa is effective for restless legs syndrome symptoms, it is not used frequently because many people who take this medication to treat restless legs syndrome develop augmentation (where symptoms occur earlier and earlier in the day). This medication can also cause symptoms to start to occur in the morning, which is referred to as rebound. Most people with restless legs syndrome who develop augmentation or rebound must switch to another medication.

Benzodiazepines (e.g., clonazepam, temazepam) may be prescribed to help with sleep, but they don't actually reduce symptoms of restless legs syndrome. Benzodiazepines help to minimize the disruption that symptoms have on sleep. They are best reserved if you have periodic restless legs syndrome symptoms or are not getting adequate results from other treatments. Side effects of benzodiazepines include daytime drowsiness or confusion, especially in seniors.

Opioids, which are narcotic analgesic (pain-killing) medications, are used most often for people with severe and unrelenting symptoms of restless legs syndrome. Some examples of medications in this category are codeine and oxycodone. Side effects include dizziness, drowsiness, nausea, vomiting, constipation, and headache. Since opioids have the potential for dependence, low-potency opioids at the lowest effective dose should be considered.

GABA derivatives such as gabapentin and pregabalin appear to work by decreasing the unpleasant sensations of restless legs syndrome and the urge to move. These agents are preferred for people who have the symptoms of restless legs syndrome while also experiencing symptoms such as insomnia, anxiety, and pain. They can also be used when other medications are not working or are not tolerated. Possible side effects of GABA derivatives include dizziness, sleepiness, fatigue, increased appetite, vision changes, weight gain, and unsteadiness.