Overview
Restless legs syndrome (RLS), also called Willis-Ekbom disease, is a neurological condition causing an irresistible urge to move the legs, usually accompanied by uncomfortable sensations described as crawling, creeping, pulling, or tingling. Symptoms worsen at rest and at night, severely disrupting sleep. Moving the legs provides temporary relief.
How common is it?
RLS affects approximately 5 to 10% of the UK population. It is more common in women and increases with age. About 2 to 3% have severe enough symptoms to significantly affect sleep and quality of life.
Causes and risk factors
Primary RLS has a strong genetic component and is linked to abnormal dopamine signalling and iron metabolism in the brain. Secondary RLS has identifiable underlying causes.
Common risk factors
- Genetic (primary RLS — often familial, onset before 45)
- Iron deficiency (even without anaemia — serum ferritin below 75 micrograms/L worsens RLS)
- Pregnancy (third trimester)
- Chronic kidney disease
- Peripheral neuropathy
- Medications: dopamine antagonists (metoclopramide, antipsychotics), antidepressants (SSRIs, TCAs), antihistamines
- Caffeine and alcohol worsening severity
Symptoms
- Uncomfortable sensations in the legs (rarely arms) described as crawling, creeping, pulling, throbbing, or itching inside the limbs
- Irresistible urge to move legs to relieve the sensation
- Symptoms start or worsen during rest or inactivity, particularly in the evening or at night
- Partial or temporary relief by movement
- Sleep disturbance and daytime fatigue
- Periodic limb movements of sleep in 80 to 90% of RLS patients (rhythmic leg jerks during sleep)
When to see a doctor
See a GP for symptoms disrupting sleep consistently. RLS is commonly misdiagnosed as circulatory problems, muscle cramps, or anxiety. Correct identification leads to effective treatment.
Diagnosis
Clinical diagnosis based on the four essential criteria (URGE): Urge to move; Relief with movement; Gets worse at rest; Evening or night predominance. Blood tests: ferritin, full blood count, renal function, thyroid function, glucose.
Treatments
Iron supplementation
Check serum ferritin. If below 75 micrograms/L, oral ferrous sulphate (taken with vitamin C, away from meals) or intravenous iron significantly improves RLS. Target ferritin above 100 micrograms/L.
Dopamine agonists
Pramipexole and ropinirole are highly effective at low doses, taken 2 to 3 hours before bedtime. Risk of augmentation with long-term use (symptoms worsen and spread), so dose should be kept as low as effective.
Alpha-2-delta ligands
Pregabalin and gabapentin are preferred over dopamine agonists for long-term treatment as they do not cause augmentation. Particularly useful when RLS is associated with peripheral neuropathy or pain.
Low-dose opioids
Low-dose codeine, tramadol, or oxycodone for refractory RLS not responding to other treatments. Used with caution due to dependence risk.
Self-care and lifestyle
- Avoid caffeine, alcohol, and antihistamines that worsen symptoms
- Moderate exercise during the day reduces symptoms (but vigorous exercise close to bedtime may worsen them)
- Hot baths, massage, and compression stockings provide temporary relief
- Mental distraction activities (reading, word puzzles) reduce symptom awareness
Prevention
No reliable prevention for primary RLS. Correcting iron deficiency promptly and avoiding triggering medications prevent secondary RLS.