Restless Legs Syndrome

What is restless legs syndrome?

Restless legs syndrome is a neurological condition causing an irresistible urge to move the legs, usually with uncomfortable sensations that worsen at rest and in the evening and are relieved by movement. It commonly disrupts sleep. Low iron stores in the brain are a frequent and treatable contributor, so ferritin should always be checked.

Causes

• Brain iron deficiency affecting dopamine signalling
• Genetic predisposition with strong family clustering
• Iron deficiency anemia
• Chronic kidney disease
• Pregnancy, particularly the third trimester
• Certain medicines including some antidepressants and antihistamines

Symptoms

• Urge to move the legs, often with crawling or tingling sensations
• Symptoms worse in the evening and at night
• Worse when sitting or lying still
• Relief with walking or stretching
• Difficulty falling asleep
• Periodic limb movements during sleep
• Daytime tiredness

Risk factors

• Family history
• Iron deficiency
• Pregnancy
• End stage kidney disease
• Peripheral neuropathy
• Use of dopamine blocking antiemetics

Diagnosis

• Clinical diagnosis using the five essential criteria
• Serum ferritin and transferrin saturation measurement
• Kidney function and glucose testing
• Review of contributing medicines
• Sleep study only if another sleep disorder is suspected

Treatment

• Iron replacement when ferritin is below about 75 micrograms per litre
• Alpha 2 delta ligands such as gabapentin or pregabalin as first line drug therapy
• Dopamine agonists used cautiously because of augmentation risk
• Stopping aggravating medicines where possible
• Regular moderate exercise and consistent sleep schedule
• Reducing caffeine, alcohol and nicotine

Self care

• Get ferritin checked, since iron replacement helps many people
• Walk or stretch when symptoms start
• Try warm or cool baths in the evening
• Keep a regular sleep schedule
• Reduce caffeine, alcohol and nicotine
• Review medicines that worsen it, including some antidepressants and antihistamines
• Use moderate regular exercise, avoiding intense late workouts

When to see a doctor

Book an appointment if:

• Symptoms disrupting sleep several nights a week
• Daytime tiredness affecting function
• Symptoms spreading to the arms or occurring earlier in the day
• Symptoms worsening on dopamine agonist treatment
• During pregnancy, since iron needs checking
• Existing kidney disease with new leg symptoms

Some symptoms need emergency care rather than an appointment. See the warning signs listed above.

Prevention

• Maintain adequate iron stores
• Keep a regular sleep pattern
• Limit caffeine, alcohol and nicotine
• Review triggering medicines before starting them
• Avoid long term dopamine agonists where alternatives exist, to prevent augmentation

Outlook

Restless legs syndrome is usually long term but very treatable. Correcting low iron resolves or greatly improves symptoms in many people. Pregnancy related cases usually settle after delivery. Alpha 2 delta ligands control symptoms effectively without the augmentation risk that made dopamine agonists problematic over time.

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Common questions