Guide to Restless Legs Syndrome

What Is Restless Legs Syndrome?

Man sitting on edge looking pensive.
Restless leg syndrome. David Hanover / Getty Images

What Is RLS?

Restless legs syndrome (RLS) is a neurological disorder characterized by unpleasant sensations in the legs and an uncontrollable urge to move when at rest in an effort to relieve these feelings.

Restless legs syndrome sensations are often described by people as:

  • burning
  • creeping
  • tugging
  • like insects crawling inside the legs

Often called paresthesias (abnormal sensations) or dysesthesias (unpleasant abnormal sensations), the sensations range in severity from uncomfortable to irritating to painful.

The most distinctive or unusual aspect of the condition is that lying down and trying to relax activates the symptoms. As a result, most people with RLS have difficulty falling asleep and staying asleep. Left untreated, the condition causes exhaustion and daytime fatigue.

Coping With RLS

Many with RLS report they are unable to concentrate, have impaired memory or fail to accomplish daily tasks. Many things are strongly affected as a result of their exhaustion including:

  • their job
  • personal relations
  • activities of daily living

RLS Underdiagnosed

Some experts estimate that RLS affects as many as 12 million Americans. However, others estimate a much higher occurrence because RLS is thought to be underdiagnosed and misdiagnosed. Some will not seek medical attention, believing that:

  • they will not be taken seriously
  • their symptoms are too mild
  • that their condition is not treatable

Doctors wrongly attribute the symptoms to:

What Is Periodic Limb Movement Disorder?

What Is Periodic Limb Movement Disorder?

More than 80 percent of people with restless legs syndrome also experience a more common condition known as Periodic Limb Movement Disorder (PLMD).

Periodic limb movement disorder is characterized by involuntary leg twitching or jerking movements during sleep that typically occur every 10 to 60 seconds, sometimes throughout the night. The symptoms cause repeated awakening and severely disrupted sleep.

Movements Caused by Periodic Limb Movement Disorder Are Involuntary

Unlike restless legs syndrome, the movements caused by periodic limb movement disorder are involuntary (people have no control over them). Although many patients with restless legs syndrome also develop periodic limb movement disorder, most people with periodic limb movement disorder do not experience restless legs syndrome.

Like restless legs syndrome, the cause of periodic limb movement disorder is also unknown.

Who Is Most Affected by Restless Legs Syndrome?

Restless legs syndrome occurs in both genders, although the incidence may be slightly higher in women. Although restless legs syndrome may begin at any age, even as early as infancy, most patients who are severely affected are middle-aged or older. In addition, the severity of the disorder appears to increase with age. Older patients experience symptoms more frequently and for longer periods of time.

What Are the Common Signs and Symptoms of RLS?

Restless Legs Syndrome Signs and Symptoms

People with restless legs syndrome feel uncomfortable sensations in their legs, especially when sitting or lying down, accompanied by an irresistible urge to move about. These sensations usually occur:

  • deep inside the leg
  • between the knee and ankle
  • in the feet, thighs, arms, and hands (more rarely)

Although the sensations can occur on just one side of the body, they most often affect both sides.

Legs Kept in Motion

Because moving the legs (or other affected parts of the body) relieves the discomfort, people with restless legs syndrome often keep their legs in motion to minimize or prevent the sensations.

  • they may pace the floor
  • constantly move their legs while sitting
  • toss and turn in bed

Most Find Restless Legs Syndrome Symptoms Lessen During The Day

Most people find the symptoms to be less noticeable during the day and more pronounced in the evening or at night, especially during the onset of sleep. For many people, the symptoms disappear by early morning, allowing for more refreshing sleep at that time.

Triggers for Restless Legs Syndrome Sensations

Other triggering situations are periods of inactivity such as:

  • long car trips
  • sitting in a movie theater
  • long-distance flights
  • immobilization in a cast
  • relaxation exercises

Do Symptoms of Restless Legs Syndrome Vary?

Restless Legs Syndrome Symptoms Vary

The symptoms of restless legs syndrome vary in severity and duration from person to person.

  • In mild cases of restless legs syndrome symptoms occur episodically, with only mild disruption of sleep onset, and causes little distress.
  • In moderately severe cases, symptoms occur only once or twice a week but result in significant delay of sleep onset, with some disruption of daytime function.
  • In severe cases of restless legs syndrome, the symptoms occur more than twice a week and result in burdensome interruption of sleep and impairment of daytime function.

Improvement of Restless Legs Syndrome Symptoms

Symptoms may begin at any stage of life, although the disorder is more common with increasing age. Sometimes people will experience spontaneous improvement over a period of weeks or months. Although rare, spontaneous improvement over a period of years also can occur. If these improvements occur, it is usually during the early stages of the disorder. In general, however, symptoms become more severe over time.

Restless Legs Syndrome and Associated Conditions

People who have both restless legs syndrome and an associated condition tend to develop more severe symptoms rapidly. In contrast, those whose restless legs syndrome is not related to any other medical condition and whose onset is at an early age show a very slow progression of the disorder and many years may pass before symptoms occur regularly.

What Causes Restless Legs Syndrome?

RLS Causes

In most cases, the cause of RLS is unknown. A family history of the condition is seen in approximately 50% of such cases, suggesting a genetic form of the disorder. People with familial RLS tend to be younger when symptoms start and have a slower progression of the condition.

Related Factors

In other cases, RLS appears to be related to the following factors or conditions, although researchers don't yet know if these factors actually cause RLS.

Treating the underlying condition often provides relief from RLS symptoms.

  • Some pregnant women experience RLS, especially in the last trimester. For most, symptoms usually disappear within 4 weeks after delivery.
  • Certain medications such as antinausea, antiseizure and antipsychotic drugs, and some cold/allergy medicines, may aggravate symptoms. Talk with your doctor about the possibility of changing drugs.


Researchers have found that caffeine, alcohol and tobacco may aggravate or trigger symptoms in patients who are predisposed to RLS. Some studies have shown that a reduction or complete elimination of such substances may relieve symptoms, although it remains unclear whether elimination of such substances can prevent RLS symptoms from occurring at all.

What Is the Diagnostic Criteria for Restless Legs Syndrome?

No Single Diagnostic Test for Restless Legs Syndrome

Currently, there is no single diagnostic test for restless legs syndrome. The disorder is diagnosed clinically by evaluating the patient's history and symptoms. Despite a clear description of clinical features, the condition is often misdiagnosed or underdiagnosed.

Four Basic Criteria for Diagnosing Restless Legs Syndrome

In 1995, the International Restless Legs Syndrome Study Group identified four basic criteria for diagnosing restless legs syndrome:

  • a desire to move the limbs, often associated with paresthesias or dysesthesias
  • symptoms that are worse or present only during rest and are partially or temporarily relieved by activity
  • motor restlessness
  • nocturnal worsening of symptoms

Periodic Limb Movement Disorder Not Necessary for Restless Legs Syndrome Diagnosis

Although about 80 percent of those with restless legs syndrome also experience periodic limb movement disorder, it is not necessary for a diagnosis of restless legs syndrome. In more severe cases, patients may experience dyskinesia (uncontrolled, often continuous movements) while awake, and some experience symptoms in one or both of their arms as well as their legs. Most people with restless legs syndrome have sleep disturbances, largely because of the limb discomfort and jerking. The result is excessive daytime sleepiness and fatigue.

How Is Restless Legs Syndrome Diagnosed?

RLS Diagnosis

Despite efforts to establish standard criteria, the clinical diagnosis of RLS is difficult to make. Doctors rely largely on patients' descriptions of symptoms and information from their medical history, including:

  • past medical problems
  • family history
  • current medications

Patients may be asked about frequency, duration, and intensity of symptoms as well as their:

  • tendency toward daytime sleep patterns and sleepiness
  • disturbance of sleep
  • daytime function

If a patient's history is suggestive of RLS, laboratory tests may be performed to rule out other conditions and support the diagnosis of RLS. Blood tests should be performed to exclude:

  • anemia
  • decreased iron stores
  • diabetes
  • renal dysfunction


Electromyography and nerve conduction studies may also be recommended to measure electrical activity in muscles and nerves, and Doppler sonography may be used to evaluate muscle activity in the legs. Such tests can document:

  • any accompanying damage or disease in nerves/nerve roots
  • other leg-related movement disorders

Negative results from tests may indicate that the diagnosis is RLS.

In some cases, sleep studies such as polysomnography are undertaken to identify the presence of PLMD.


RLS diagnosis is difficult with children because the doctor relies heavily on the patient's explanations of symptoms, which, given the nature of the symptoms of RLS, can be difficult for a child to describe. The syndrome can sometimes be misdiagnosed as growing pains or ADD.

How Is Restless Legs Syndrome Treated?

RLS Treatment

Although movement brings relief to those with RLS, it is generally only temporary. However, RLS can be controlled by finding any possible underlying disorder. Often, treating the associated medical condition, such as peripheral neuropathy or diabetes, will alleviate many symptoms. For patients with idiopathic RLS, treatment is directed toward relieving symptoms.

For those with mild to moderate symptoms, prevention is key, and many doctors suggest certain lifestyle changes and activities to reduce or eliminate symptoms. Relief may be provided by decreasing use of:

  • caffeine
  • alcohol
  • tobacco

Doctors may suggest that certain people take supplements to correct deficiencies of:

  • iron
  • folate
  • magnesium

Other RLS Treatments

Studies also have shown that maintaining a regular sleep pattern can reduce symptoms.

Some individuals, finding that RLS symptoms are minimized in the early morning, change their sleep patterns. Others have found that a program of regular moderate exercise helps them sleep better; on the other hand, excessive exercise has been reported by some patients to aggravate RLS symptoms. Some patients can help relieve symptoms by:

  • taking a hot bath
  • massaging the legs
  • using a heating pad or ice pack

Although many patients find some relief with such measures, rarely do these efforts completely eliminate symptoms


Doctors also may suggest a variety of medications to treat RLS. Generally, doctors choose from:

  • dopaminergics
  • benzodiazepines
  • opioids
  • anticonvulsants

What Medications Are Used to Treat Restless Legs Syndrome?

RLS Drug Options

No one drug is effective for everyone with RLS. What may be helpful for some may worsen symptoms for another. Drugs taken regularly can lose their effect, making it necessary to change drugs.


Dopaminergic agents have shown to reduce RLS symptoms and PLMD and are considered the initial treatment of choice. Good short-term results of treatment with levodopa plus carbidopa have been reported, although most patients eventually will develop augmentation, meaning that symptoms are reduced at night but begin to develop earlier in the day than usual.

Dopamine agonists that may be effective in some and are less likely to cause augmentation include:

  • pergolide
  • pramipexole
  • ropinirole


Benzodiazepines such as clonazepam and diazepam are prescribed for patients who have mild or intermittent symptoms. They help patients obtain a more restful sleep but they do not fully alleviate symptoms and can cause daytime sleepiness. Because these drugs also may induce or aggravate sleep apnea, they should not be used in people with this condition.


For severe symptoms, opioids are prescribed for their ability to induce relaxation and diminish pain. Opioids include:

  • codeine
  • propoxyphene
  • oxycodone

Side effects include:

  • dizziness
  • nausea
  • vomiting
  • risk of addiction


Anticonvulsants such as carbamazepine and gabapentin are useful for some patients, as they decrease the sensory disturbances. Side effects include:

  • dizziness
  • fatigue
  • sleepiness

What Is the Prognosis for People With Restless Legs Syndrome?

Prognosis for People With Restless Legs Syndrome

Restless legs syndrome is generally a lifelong condition for which there is no cure.

Restless legs syndrome symptoms may gradually worsen with age though more slowly for those with the idiopathic form of restless legs sydrome than for patients who also suffer from an associated medical condition. Nevertheless, current therapies can:

  • control the disorder
  • minimize restless legs syndrome symptoms
  • increase periods of restful sleep


In addition, some patients have remissions, periods in which symptoms decrease or disappear for days, weeks, or months, although symptoms usually eventually reappear.

A diagnosis of restless legs syndrome does not indicate the onset of another neurological disease.

Source: NIH Publication No. 01-4847 (edited)

Continue Reading