Sleep-related movement disorders
Restless Legs Syndrome
An irresistible urge to move your legs, usually with uncomfortable sensations, that is worse at rest and in the evening and eases with movement.
Overview
Restless legs syndrome (RLS), also called Willis-Ekbom disease, is a neurological condition that causes an urge to move your legs, typically with unpleasant sensations described as creeping, crawling, pulling, itching or aching. Symptoms appear or get worse when you sit or lie still, especially in the evening and at night, and are relieved, at least temporarily, by walking or stretching.
Because symptoms peak at bedtime, RLS often makes it hard to fall asleep and stay asleep. Many people with RLS also have periodic limb movements, repetitive leg jerks during sleep.
Low iron in the brain plays a key role, so checking iron levels is one of the first steps. Guidance from the American Academy of Sleep Medicine published in 2024 shifted first-line treatment toward iron replacement and medicines called gabapentinoids, and away from routine long-term use of dopamine agonists because of a worsening effect called augmentation.
A 2024 systematic review estimated that about 7% of adults worldwide aged 20 to 79 have restless legs syndrome.
Common symptoms
- An urge to move the legs, often with uncomfortable sensations
- Symptoms that start or worsen during rest or inactivity
- Relief with movement such as walking or stretching
- Symptoms that are worse in the evening or at night
- Difficulty falling or staying asleep
- Leg jerks during sleep (periodic limb movements)
- Daytime tiredness from poor sleep
- Sometimes similar sensations in the arms
Causes and risk factors
- Iron deficiency, even without anaemia
- Family history and genetics
- Pregnancy, especially the third trimester
- Chronic kidney disease and dialysis
- Peripheral neuropathy
- Medicines such as sedating antihistamines, some antidepressants and anti-nausea or antipsychotic drugs that block dopamine
- Alcohol, caffeine and nicotine
- Sleep deprivation
How it is diagnosed
RLS is diagnosed clinically using five essential criteria: an urge to move the legs, usually with uncomfortable sensations; onset or worsening during rest; relief with movement; worsening in the evening or night; and symptoms not explained by another condition such as leg cramps, arthritis or positional discomfort.
Blood tests for iron, including ferritin and transferrin saturation, are recommended for everyone with clinically significant RLS. A sleep study is not needed for diagnosis but may be used if another sleep disorder is suspected.
Treatment options
Iron replacement
Oral or intravenous iron is recommended when iron levels are low by RLS standards, which are higher than general population cut-offs. Your clinician will check ferritin and transferrin saturation.
Gabapentinoids
Gabapentin, gabapentin enacarbil and pregabalin are strongly recommended in 2024 AASM guidance.
Avoiding triggers
Reviewing medicines and reducing alcohol and caffeine can improve symptoms.
Dopamine agonists
Pramipexole, ropinirole and rotigotine work in the short term but are no longer recommended for standard long-term use because they can cause augmentation, where symptoms become stronger and start earlier.
Specialist options
For severe, resistant RLS, specialists may use carefully monitored low-dose opioids or other approaches.
Non-drug therapy
A prescription device that delivers tonic motor activation to the legs is another option in the guideline.
What you can do yourself
- Walk, stretch or massage your legs when symptoms start
- Try a warm bath or warm or cool packs on your legs
- Keep a regular sleep schedule
- Cut back on caffeine, alcohol and nicotine
- Do engaging activities, such as puzzles, in the evening when sitting
- Get regular moderate exercise, avoiding intense workouts late at night
- Ask a pharmacist whether any of your medicines can worsen RLS
When to see a doctor
- Leg sensations regularly keep you from falling or staying asleep
- Symptoms are getting worse or starting earlier in the day while on treatment
- You are pregnant and have new RLS symptoms
- You have kidney disease, diabetes or neuropathy along with leg symptoms
- You have not had your iron levels checked
Frequently asked questions
Does iron help restless legs?
Iron deficiency is a common contributor to RLS, and treating it can reduce or even resolve symptoms. RLS specialists use higher target levels than for anaemia, so ask your clinician to check ferritin and transferrin saturation.
What is augmentation?
Augmentation is a worsening of RLS caused by long-term dopamine agonist treatment. Symptoms start earlier in the day, become more intense or spread to the arms. It is the main reason guidelines now discourage these drugs as standard long-term treatment.
Is RLS just leg cramps?
No. Cramps are painful muscle tightening that you can see or feel. RLS is an urge to move with uncomfortable sensations that eases with movement and follows a daily pattern.
Can RLS start in pregnancy?
Yes. RLS is more common in pregnancy, especially late pregnancy, and often improves after delivery. Iron status should be checked, and medicines need careful discussion with your obstetric team.
Do magnesium supplements help?
Evidence that magnesium helps RLS is limited and inconsistent. Talk with a clinician before trying supplements, particularly if you have kidney disease.
Sources
This page is general information, not a diagnosis or medical advice. Read our medical disclaimer.