Restless Legs Syndrome: Symptoms, Causes & Treatment Guide

What Is Restless Legs Syndrome?

Restless Legs Syndrome (RLS), also called Willis-Ekbom Disease, is a neurological sensorimotor disorder characterized by uncomfortable sensations in the legs and an irresistible urge to move them. Symptoms typically occur during periods of rest, worsen in the evening and at night, and are temporarily relieved by movement.

Restless Legs Syndrome is one of the most common neurological conditions, affecting between 5% and 15% of the general population according to epidemiological studies. The condition was first formally described by Swedish neurologist Karl-Axel Ekbom in the 1940s, though accounts of similar symptoms date back centuries. The condition is now officially named Willis-Ekbom Disease by the International Restless Legs Syndrome Study Group (IRLSSG), honoring both Thomas Willis who first described it in 1685 and Karl Ekbom who provided the modern clinical definition.

The underlying mechanism of RLS involves dysfunction in the brain's dopamine system, which plays a crucial role in controlling movement. Research has shown that people with RLS have reduced dopamine receptor binding in certain brain regions, particularly the substantia nigra and putamen. Additionally, iron plays an essential role in dopamine synthesis, and iron deficiency in the brain is strongly associated with RLS symptoms, even when blood iron levels appear normal.

RLS significantly impacts quality of life, primarily through sleep disruption. The urge to move typically intensifies during the evening and night hours, making it difficult to fall asleep and stay asleep. This circadian pattern is thought to relate to natural fluctuations in dopamine levels, which are lowest at night. Chronic sleep deprivation from RLS can lead to daytime fatigue, difficulty concentrating, mood changes, and reduced productivity.

Primary versus Secondary RLS

Restless Legs Syndrome is classified into two main types based on whether an underlying cause can be identified. Understanding which type you have is important because it affects both prognosis and treatment approach.

Primary (idiopathic) RLS occurs without an identifiable underlying cause. This form typically begins before age 40, progresses gradually over time, and has a strong genetic component—40-60% of patients have a first-degree relative with the condition. Primary RLS is a chronic, lifelong condition that cannot be cured, though symptoms can be effectively managed with treatment.

Secondary RLS develops as a result of an underlying condition or triggering factor. Common causes include iron deficiency, chronic kidney disease (particularly in dialysis patients), pregnancy, certain medications, and peripheral neuropathy. Secondary RLS often has a later onset, may progress more rapidly, and importantly, may improve or completely resolve when the underlying cause is addressed.

What Are the Symptoms of Restless Legs Syndrome?

The hallmark symptoms of RLS include uncomfortable sensations in the legs described as crawling, creeping, pulling, itching, or tingling, accompanied by an irresistible urge to move. Symptoms occur during rest, are worse in the evening and night, and are temporarily relieved by movement.

The sensory symptoms of Restless Legs Syndrome are often difficult for patients to describe precisely. People commonly use terms like "crawling," "creeping," "pulling," "itching," "tingling," "burning," "aching," or "electric" to describe the sensations. Some describe it as feeling like insects are crawling under the skin, while others compare it to carbonated water flowing through their veins. These sensations typically occur deep within the legs rather than on the skin surface, most commonly in the calves, though they can affect the thighs and feet as well.

The sensations create what patients describe as an overwhelming, irresistible urge to move the legs. This urge is not simply a desire to move but feels compulsive—as though the legs must move. Walking, stretching, or simply moving the legs provides immediate but temporary relief. However, once movement stops and the person is at rest again, symptoms typically return within minutes.

A defining characteristic of RLS is the circadian pattern of symptoms. Symptoms are typically minimal or absent in the morning and gradually worsen throughout the day, reaching peak intensity in the evening and night hours. This pattern reflects the natural daily rhythm of dopamine levels in the brain, which are lowest during nighttime hours. The evening and nighttime worsening is one of the four essential diagnostic criteria established by the International Restless Legs Syndrome Study Group.

The Four Essential Diagnostic Criteria

The IRLSSG has established four criteria that must ALL be present for a diagnosis of RLS:

• Urge to move the legs: An often irresistible urge to move the legs, usually accompanied or caused by uncomfortable sensations in the legs
• Rest triggers symptoms: The urge to move and sensations begin or worsen during periods of rest or inactivity such as lying down or sitting
• Movement relieves symptoms: The urge to move and sensations are partially or totally relieved by movement such as walking or stretching, at least as long as the activity continues
• Evening/night worsening: The urge to move and sensations occur exclusively or predominantly in the evening or at night rather than during the day

Impact on Sleep and Daily Function

The sleep disruption caused by RLS can be severe and significantly impacts daily functioning. Patients often report difficulty falling asleep due to symptoms that intensify when lying down. Even after falling asleep, many people with RLS experience periodic limb movements of sleep (PLMS)—repetitive leg jerks that occur every 20-40 seconds and can cause frequent awakenings throughout the night.

The chronic sleep deprivation resulting from RLS leads to a cascade of daytime consequences. Patients commonly report excessive daytime sleepiness, fatigue, difficulty concentrating, and impaired memory. Over time, chronic sleep loss is associated with increased risk of depression, anxiety, and reduced quality of life. The condition also affects social activities—patients may avoid situations requiring prolonged sitting such as long flights, theater performances, or meetings.

What Causes Restless Legs Syndrome?

RLS is caused by dysfunction in brain dopamine pathways and often involves brain iron deficiency. Primary RLS has a strong genetic component with multiple gene variants identified. Secondary RLS can be caused by iron deficiency, kidney disease, pregnancy, peripheral neuropathy, or certain medications including antihistamines and antidepressants.

The exact cause of Restless Legs Syndrome involves complex interactions between genetic factors, brain iron metabolism, and dopamine neurotransmission. While researchers have made significant progress in understanding these mechanisms, the complete picture remains under investigation. What is clear is that RLS is a real neurological condition with identifiable biological underpinnings—it is not a psychological problem or imaginary symptom.

Dopamine Dysfunction

The dopamine system plays a central role in RLS pathophysiology. Dopamine is a neurotransmitter involved in movement control, and imaging studies have shown that people with RLS have reduced dopamine receptor binding in specific brain regions. This dopamine dysfunction helps explain why dopamine-enhancing medications are often effective treatments for RLS.

The circadian pattern of RLS symptoms—worsening at night—correlates with natural fluctuations in brain dopamine levels, which are lowest during evening and nighttime hours. This connection between dopamine rhythm and symptom timing provides further evidence for dopamine's central role in the condition.

Iron Deficiency in the Brain

Iron is essential for dopamine synthesis and proper dopamine receptor function in the brain. Research has consistently shown that people with RLS have lower iron levels in specific brain regions, even when their blood iron levels appear normal. Brain iron deficiency appears to disrupt dopamine neurotransmission, contributing to RLS symptoms.

For this reason, serum ferritin (a marker of iron stores) is routinely checked in RLS patients. Current guidelines suggest that a ferritin level below 75 ng/mL may contribute to RLS symptoms and warrant iron supplementation, even though this level would be considered "normal" by standard laboratory ranges. Some patients experience significant symptom improvement with iron therapy alone.

Genetic Factors

Primary RLS has a strong hereditary component. Studies show that 40-60% of patients with RLS have a first-degree relative with the condition, and the risk of developing RLS is 6-7 times higher if a parent has the condition. Genome-wide association studies have identified several genetic variants associated with RLS risk, including variants in genes involved in brain development and iron metabolism.

Early-onset RLS (before age 40) is particularly likely to have a genetic basis and tends to progress more slowly than later-onset disease. If you have RLS that started at a young age and have family members with similar symptoms, your condition likely has a strong genetic component.

Secondary Causes of RLS

Secondary RLS develops as a result of an identifiable underlying condition or trigger. Common secondary causes include:

• Iron deficiency anemia: Even mild iron deficiency can trigger or worsen RLS symptoms
• Chronic kidney disease: Up to 40% of patients on dialysis have RLS, likely related to iron metabolism and toxin accumulation
• Pregnancy: Symptoms commonly appear or worsen during pregnancy, especially in the third trimester, often resolving after delivery
• Peripheral neuropathy: Nerve damage from diabetes or other causes can trigger RLS-like symptoms
• Medications: Certain drugs can cause or worsen RLS including antihistamines (diphenhydramine), antidepressants (SSRIs, TCAs), anti-nausea drugs (metoclopramide), and antipsychotics
• Spinal cord conditions: Lesions or damage to the spinal cord can be associated with RLS

How Is Restless Legs Syndrome Diagnosed?

RLS is diagnosed primarily through clinical evaluation based on the four IRLSSG essential criteria. There is no specific test for RLS, but blood tests for ferritin (iron stores), kidney function, and thyroid function help identify contributing factors. Sleep studies may assess periodic limb movements but are not required for diagnosis.

The diagnosis of Restless Legs Syndrome is clinical, meaning it is based on the patient's symptom description and medical history rather than a specific laboratory test or imaging study. A doctor experienced with RLS can often make the diagnosis in a single office visit by asking targeted questions about symptom characteristics, timing, and relieving factors.

The diagnostic process involves confirming that all four IRLSSG essential criteria are met: an urge to move the legs accompanied by uncomfortable sensations, symptoms that begin or worsen at rest, temporary relief with movement, and worsening in the evening or night. Additionally, the doctor must ensure that symptoms are not better explained by another condition such as leg cramps, positional discomfort, or anxiety.

Medical History and Physical Examination

Your doctor will ask detailed questions about your symptoms, including when they occur, what they feel like, what makes them better or worse, and how they affect your sleep and daily life. They will also inquire about your medical history, family history of RLS, current medications, and lifestyle factors such as caffeine and alcohol consumption.

A physical examination helps rule out other conditions that can mimic RLS. This typically includes a neurological examination to assess for peripheral neuropathy and a vascular examination to check for circulation problems. The examination also looks for signs of conditions that can cause secondary RLS.

Laboratory Testing

While there is no specific blood test for RLS, several tests help identify contributing factors and secondary causes:

• Serum ferritin: The most important test—ferritin below 75 ng/mL may contribute to RLS and indicates potential benefit from iron supplementation
• Complete blood count: Checks for anemia and other blood abnormalities
• Kidney function tests: Chronic kidney disease is a common cause of secondary RLS
• Thyroid function: Thyroid disorders can contribute to RLS-like symptoms
• Blood glucose: Diabetes and peripheral neuropathy can cause similar symptoms
• Vitamin B12 and folate: Deficiencies can cause neurological symptoms

Sleep Studies

Polysomnography (overnight sleep study) is not required for RLS diagnosis but may be useful in certain situations. The test can detect periodic limb movements of sleep (PLMS), which occur in about 80% of RLS patients. A sleep study may be recommended if the diagnosis is uncertain, if the patient does not respond to treatment as expected, or if there is suspicion of concurrent sleep apnea.

How Is Restless Legs Syndrome Treated?

RLS treatment begins with addressing underlying causes like iron deficiency and avoiding triggers. Mild symptoms often improve with lifestyle modifications. For moderate to severe symptoms, medications including dopamine agonists (pramipexole, ropinirole) and alpha-2-delta ligands (gabapentin, pregabalin) are effective first-line treatments.

Treatment for Restless Legs Syndrome follows a stepwise approach based on symptom severity and underlying factors. The first priority is addressing any reversible causes—correcting iron deficiency, managing underlying conditions like kidney disease, and eliminating medications that may be worsening symptoms. For many patients with mild symptoms, lifestyle modifications alone provide adequate relief.

When lifestyle changes are insufficient, medication becomes necessary. Current guidelines from the International Restless Legs Syndrome Study Group recommend either dopamine agonists or alpha-2-delta ligands as first-line pharmacological treatments. The choice between these classes depends on individual patient factors including coexisting conditions, potential side effects, and treatment goals.

Iron Supplementation

Iron therapy is fundamental in RLS management. Current guidelines recommend checking serum ferritin in all RLS patients and treating with iron supplementation if ferritin is below 75 ng/mL—even though this level is often considered "normal" by standard laboratory ranges. The goal is to raise ferritin above 75 ng/mL, ideally to 100-200 ng/mL.

Oral iron supplementation (typically ferrous sulfate 325 mg with vitamin C to enhance absorption) is usually tried first. Iron should be taken on an empty stomach for best absorption, though this can cause gastrointestinal side effects in some people. If oral iron is not tolerated or ferritin levels do not increase adequately, intravenous iron infusion may be recommended and can produce faster, more reliable results.

Lifestyle Modifications

Non-pharmacological approaches are important for all RLS patients and may be sufficient for those with mild symptoms. Evidence-based lifestyle modifications include:

• Regular moderate exercise: Light to moderate physical activity, particularly earlier in the day, can reduce symptoms; avoid intense exercise close to bedtime
• Sleep hygiene: Maintain consistent sleep and wake times, create a cool and comfortable sleep environment, avoid screens before bed
• Avoid triggers: Limit or eliminate caffeine, alcohol, and nicotine, especially in the afternoon and evening
• Leg massage: Gentle massage or stretching can provide temporary relief when symptoms occur
• Temperature therapy: Warm baths, heating pads, or alternatively cool compresses may help some patients
• Mental distraction: Engaging activities like puzzles, reading, or conversation can help reduce symptom awareness

Dopamine Agonist Medications

Dopamine agonists have been a mainstay of RLS treatment for decades. These medications stimulate dopamine receptors in the brain, compensating for the dopamine dysfunction underlying RLS. Approved options include pramipexole (Mirapex), ropinirole (Requip), and rotigotine (Neupro patch).

Dopamine agonists are highly effective, with most patients experiencing significant symptom improvement. However, long-term use carries risk of augmentation—a paradoxical worsening of symptoms where they begin earlier in the day, spread to other body parts, or become more intense. Augmentation occurs in 7-8% of patients per year with dopamine agonists. To minimize this risk, current guidelines recommend using the lowest effective dose and considering alpha-2-delta ligands as an alternative first-line option.

Alpha-2-Delta Ligand Medications

Alpha-2-delta ligands including gabapentin, gabapentin enacarbil (Horizant), and pregabalin (Lyrica) are increasingly recommended as first-line treatments. These medications affect calcium channels in the nervous system and are effective for RLS symptoms, particularly when pain is a prominent feature.

Alpha-2-delta ligands have a lower risk of augmentation compared to dopamine agonists, making them attractive for long-term use. Common side effects include drowsiness, dizziness, and weight gain. These medications may be particularly suitable for patients with coexisting conditions like pain syndromes, anxiety, or insomnia.

Other Treatment Options

For patients who do not respond adequately to first-line treatments or who experience augmentation, several other options exist:

• Opioid medications: Low-dose opioids can be effective for severe, refractory RLS, though their use requires careful monitoring
• Benzodiazepines: Clonazepam may help with sleep, though it does not directly treat RLS sensations
• Pneumatic compression devices: FDA-approved devices that apply sequential pressure to the legs during rest
• Transcranial magnetic stimulation: Emerging treatment showing promise in research studies

When Should You See a Doctor for Restless Legs?

See a doctor if RLS symptoms occur several times per week and affect your sleep or daily life, if self-help measures don't provide relief, if symptoms are progressively worsening, or if you have signs of iron deficiency. Seek prompt evaluation for sudden onset of symptoms or symptoms accompanied by other neurological signs.

Many people experience occasional leg restlessness or discomfort that does not require medical attention. However, when symptoms become frequent, disruptive to sleep, or interfere with daily activities, professional evaluation is warranted. A doctor can confirm the diagnosis, check for underlying conditions, and recommend appropriate treatment.

You should see a healthcare provider if you experience leg discomfort and urge to move that occurs several times per week and significantly affects your ability to fall asleep or stay asleep, causes daytime fatigue or impaired functioning, does not improve with lifestyle modifications, or is progressively getting worse over time.

Additionally, seek medical evaluation if your symptoms started suddenly without obvious cause, if you have symptoms of iron deficiency (fatigue, shortness of breath, pale skin), if you notice symptoms spreading to your arms or other body parts, or if you have other neurological symptoms like weakness or numbness.

Preparing for Your Appointment

To make the most of your medical appointment, consider keeping a symptom diary for 1-2 weeks beforehand. Note when symptoms occur, how severe they are, what seems to trigger or relieve them, and how they affect your sleep. Bring a list of all medications you take, including over-the-counter drugs and supplements, as some can cause or worsen RLS.

Be prepared to describe your symptoms in detail. Doctors find it helpful when patients describe the actual sensations they feel, where exactly they occur, and how the urge to move relates to these sensations. Also note any family history of RLS or similar symptoms, as this information aids diagnosis.

Can Restless Legs Syndrome Occur During Pregnancy?

RLS affects up to 26% of pregnant women, typically appearing or worsening in the third trimester. Pregnancy-related RLS is usually temporary and resolves within weeks after delivery. Iron and folate deficiency during pregnancy are contributing factors. Treatment focuses on non-pharmacological approaches and iron supplementation when needed.

Restless Legs Syndrome is remarkably common during pregnancy, affecting up to one in four pregnant women. For many, pregnancy triggers their first experience with RLS symptoms, while women with pre-existing RLS often notice significant worsening. Symptoms typically peak during the third trimester and, reassuringly, usually resolve within weeks to months after delivery.

Several factors contribute to pregnancy-related RLS. Iron and folate demands increase substantially during pregnancy, and deficiencies in these nutrients are strongly associated with RLS. Hormonal changes, particularly rising estrogen and progesterone levels, may also play a role. Additionally, the physical demands of pregnancy can affect circulation and nerve function in the legs.

Management During Pregnancy

Treatment of RLS during pregnancy prioritizes non-pharmacological approaches. Iron supplementation is safe and often beneficial—checking ferritin levels and supplementing if low is a first-line intervention. Folate supplementation, already standard in prenatal care, may also help. Lifestyle modifications including moderate exercise, leg massage, and avoiding known triggers (caffeine, alcohol) are emphasized.

Most RLS medications have not been adequately studied in pregnancy and are generally avoided, particularly in the first trimester. When symptoms are severe and significantly affect quality of life, some medications may be considered with careful discussion of risks and benefits. Low-dose clonazepam or opioids are sometimes used for severe cases under close medical supervision.

The good news is that pregnancy-related RLS is typically temporary. Symptoms usually begin improving within days to weeks after delivery, though some women notice them during subsequent pregnancies. Women who develop RLS during pregnancy may have a slightly higher risk of developing persistent RLS later in life.

What Is It Like Living With Restless Legs Syndrome?

Living with RLS requires ongoing management through a combination of medication, lifestyle adjustments, and coping strategies. While the condition is chronic for most people with primary RLS, effective treatment allows many patients to achieve good symptom control and maintain quality of life.

Living with Restless Legs Syndrome means adapting daily routines and activities to manage symptoms and minimize their impact. Many people with well-controlled RLS lead full, active lives, but this often requires attention to sleep habits, activity levels, dietary choices, and medication timing. Understanding the condition and actively participating in its management improves outcomes.

Practical adjustments can make a significant difference. When attending events requiring prolonged sitting—flights, theater performances, meetings—choosing aisle seats allows easier movement when symptoms arise. Planning long drives with regular breaks, keeping the bedroom cool and comfortable, and timing medications to provide peak coverage during symptom-prone hours all help maintain quality of life.

The psychological impact of RLS should not be underestimated. Chronic sleep deprivation can lead to anxiety and depression, and the invisible nature of the condition sometimes leads to frustration when others don't understand. Connecting with support groups, either in-person or online, provides valuable peer support and practical tips. Organizations like the RLS Foundation offer educational resources and community connections.