Imagine lying in bed, feeling exhausted and ready for sleep, while your legs feel jumpy and uncomfortable, giving you an insatiable urge to bounce and move them, keeping you from getting that sleep you crave.
Poor sleep health affects up to 25% of Americans, and for up to 10% of that population, the issue could be due to an unpleasant, uncomfortable, and annoying urge to squirm, otherwise known as restless legs syndrome (RLS) or Willis-Ekbom Disease.
“Restless legs syndrome is a sleep disorder where patients often feel like they want to move their leg constantly or cannot get into a comfortable position during sleep,” says family medicine physician and author Dr. Shilpi Agarwal. “In some cases, patients note they feel a sensation of aching or burning or something moving on the leg that makes them want to move it around or shake it. This is extremely disruptive to their sleep patterns.”
While RLS symptoms can occur during periods of extended sitting or inactivity, they most frequently pop up in the late afternoon or evening and tend to be most severe at night when a person is lying down or otherwise resting. While RLS is technically a neurological sensory disorder with symptoms rooted in the brain, it’s categorized as both a sleep disorder and a movement disorder, because the symptoms are triggered by rest and an attempt to sleep and because movement is the only thing that brings immediate symptom relief.
According to Dr. Chris Winter, sleep neurologist and Sleep.com advisor, RLS is one of the more common disorders he sees in his practice. The episode of his “Sleep Unplugged” podcast devoted to the topic is one of the most popular to date. “Probably because so many people struggle with the disorder and there is so little available information,” he speculates.
What are the symptoms of RLS?
RLS symptoms can vary from person to person and even from day to day in the same person. The most common symptom is an irresistible urge to move, accompanied by uncomfortable sensations in the legs ranging from aching or throbbing to pulling, itching, and crawling. Though these sensations can also occur in other parts of the body like the arms or — more rarely — the chest or head, they most frequently occur in the legs, thus the moniker restless legs syndrome. Usually, the discomfort and urge to move will affect both sides, but in some cases it alternates between sides or affects just one side.
What is the cause of restless legs syndrome?
The cause of RLS is unknown in most cases but could include hormonal changes, iron deficiency, certain medications, or illnesses. Experts say there does tend to be a genetic component, especially if the condition presents before age 40.
Hormonal changes have also been shown to trigger or worsen RLS symptoms in some individuals, particularly during pregnancy. For pregnant women, the third trimester is when RLS symptoms are most likely to present, with symptoms typically disappearing after childbirth.
Some evidence also indicates that low iron levels may contribute to the condition, as low levels of the mineral have been shown to lead to a decline in dopamine, a neurotransmitter involved in movement, cognition, mood, and other functions of the body. “RLS has been shown to be related to brain iron deficiency,” says Dr. Funke Afolabi-Brown, sleep medicine physician and founder of Restful Sleep MD. “Iron is important in our brain’s ability to make brain dopamine, which is important in movement.”
Other potential causes or contributors to restless legs can include certain medications like antinausea drugs and diuretics, as well as serious illnesses like end-stage renal disease. It’s important to work with an experienced physician to review your medications and symptoms and rule out any underlying causes to determine whether RLS is rooted in a serious health problem.
Why does RLS happen at night?
Because restless legs are associated with decreased dopamine, many experts speculate that the symptoms tend to present at night because levels of the neurotransmitter naturally drop toward the end of the day. “This disorder is circadian in nature and tends to correspond with the natural drop in dopamine levels we have later in the evening/night,” Winter says. “This condition is a huge cause of insomnia, and many who have the condition are strangely not entirely aware of it.”
Afolabi-Brown says the fact that most people aren’t as active or mobile in the evenings likely contributes to the surfacing of symptoms as well. The perfect storm of inactivity and reduced dopamine may create the formula for people prone to RLS to experience unpleasant sensations as they try to get rest. “As the symptoms occur in the evening, this tends to delay sleep onset,” Afolabi-Brown says. “Patients may want to fall asleep, and the discomfort and urge to move their legs either keep them awake or wake them out of sleep.”
Because RLS can lead to sleep deprivation, many people who experience the symptoms tend to also suffer from exhaustion and daytime sleepiness. It’s estimated that untreated RLS can result in a 20% reduction in overall productivity (about one workday lost each week) and can contribute to depression and anxiety as well.
“I often see patients suffering from broken sleep, extreme overtiredness, and even depressive symptoms while having RLS because it does not allow a person to get restful sleep or a full consecutive night of rest,” Agarwal says.
How is RLS officially diagnosed?
There is no single test for RLS, so health professionals typically use five basic criteria to clinically diagnose the disorder:
- The urge to move the legs due to unpleasant sensation
- Symptoms that are worse with rest or inactivity
- Symptoms that begin or worsen in the evening
- Symptoms that are partially or totally relieved by movement
- The above four criteria are not due to another medical or behavioral condition
“RLS is a clinical diagnosis, meaning that we usually can determine this is the cause of a patient’s symptoms purely based on history and physical exam,” Agarwal says. “The symptoms of RLS can be a sign of another underlying disease, iron deficiency, thyroid problems, or depression, so patients should be screened for these issues as well.”
Afolabi-Brown also points out that RLS can sometimes be confused for other medical conditions, so it’s important to work with a physician who has experience diagnosing and treating the syndrome. “Periodic limb movement disorder (PLMD) presents as episodic limb movements that occur in a stereotypical fashion during sleep,” she says. “These movements can lead to arousal out of sleep. However, the person is often unaware of the movements. The diagnosis of PLMD (unlike RLS) is made based on specific findings of these stereotypic movements during a sleep study. PLMD may occur with or without the presence of RLS.”
For children and adolescents, it’s important to determine whether their symptoms are instead a natural part of growth. “Another common complaint that is confused with RLS is growing pains,” Afolabi-Brown says. “Growing pains are experienced in children, and they are different from RLS in that patients are often complaining of pains, which may not improve with movement.”
What is the best treatment for RLS?
Though there is a variety of treatment options for RLS directed at alleviating or managing symptoms, the optimal treatment plan depends on the patient, the severity of the symptoms, and the clinical recommendations from an experienced physician.
Some people may want to start by trying holistic, non-medicated treatment options. “For some, iron therapy can be used with success. Magnesium might be helpful for some. Hot baths, exercise, and weighted blankets can be helpful for some. There are some compression/vibrating devices as well, too,” says Winter.
“Avoiding triggers like alcohol or caffeine is important because these can make symptoms worse,” says Agarwal. Other at-home remedies recommended to alleviate symptoms are massages, exercise, and heating or cooling pads.
“The medications do have side effects, so if there are ways to reduce symptoms before using medications, I would recommend speaking with your doctor about that,” Agarwal says.
“There are four FDA-approved medications if a patient chooses to use medications,” Winter says. The FDA has approved the anti-seizure medication gabapentin enacarbil for the treatment of moderate to severe RLS. The FDA has also approved the use of the dopaminergic agents (medications that increase the effect of dopamine) ropinirole, pramipexole, and rotigotine to treat moderate to severe RLS; the combination of levodopa and carbidopa has been shown to be effective when used intermittently (not daily), and other prescription medications including opioids and benzodiazepines are sometimes used to treat RLS.
It is important to be aware that long-term use of these medications can lead to worsening of symptoms, however. “There is a phenomenon called augmentation, which occurs in people with RLS, where symptoms worsen with medications,” Afolabi-Brown says. “This occurs especially when people are on long-term dopaminergic treatment.”
No matter the course of treatment you prefer, it’s important to work with a medical professional to address the situation and attempt to correct any underlying medical causes. Hopefully with the right approach, your restless legs syndrome and sleep issues can be improved.