Treatment for Restless Legs Syndrome: Lifestyle Changes, Medications, and More

RLS has a “circadian rhythm to it,” says John Cline, PhD, a clinical psychologist specializing in sleep medicine in Cheshire, Connecticut, and a diplomate of the American Board of Sleep Medicine. “It tends to get worse toward nighttime, making it difficult to ignore. It can have an extremely negative impact on falling asleep and staying asleep,” he says.

Keep reading to find out what the guidelines say about how best to treat symptoms of RLS.

Before you start any treatment, it’s important to talk to your healthcare professional. Your doctor will consider your age, overall health, and other factors when suggesting a treatment plan that’s best for you.

• Antidepressants
• Antipsychotics
• Antihistamines

• Consuming alcohol
• Consuming caffeine
• Having untreated obstructive sleep apnea (OSA)

Try eliminating or reducing caffeine and alcohol consumption to see if it improves your symptoms, and let your doctor know which medications you take and if you’ve been diagnosed with or suspect you may have sleep apnea. Switching to a different drug or treating your sleep apnea may potentially resolve RLS.

Several prescription medications are used to treat RLS. They’re typically taken at night, one or two hours before symptoms begin, says Preeti Devnani, MD, a staff physician at the Cleveland Clinic Sleep Disorders Center and a fellow of the AASM. Some are taken only when symptoms tend to crop up, such as before a long flight. Others are taken daily. Each medication comes with its own set of potential side effects.

“Ask your healthcare provider what medication may be best for you given the severity and timing of your symptoms,” Dr. Devnani says.

Gabapentinoids as First-Line Treatment

• gabapentin (Neurontin, Gralise)
• gabapentin enacarbil (Horizant)
• pregabalin (Lyrica, Lyrica CR)

“Most patients tolerate these medications well,” says Alon Avidan, MD, MPH, professor of neurology at UCLA and director of the UCLA Sleep Disorders Center in Los Angeles.

“However, as with most medications that work on the brain, the side effects may be a limitation and may include dizziness, sleepiness, fatigue, swelling of the legs, and weight gain. The side effects may be reduced when patients begin therapy at low doses and increase to higher doses slowly over time.”

Patients should also be evaluated for misuse risks, adds Devnani, as some patients may become addicted to the drugs. “Side effects can also include respiratory depression in patients with untreated obstructive sleep apnea,” she says.

Dopaminergic Drugs May Do More Harm Than Good in the Long Run

• ropinirole (Requip)
• pramipexole (Mirapex)
• rotigotine (Neupro)

Your healthcare provider should carefully advise you of the short- and long-term risks and side effects of these drugs.

Switching From Dopaminergic Drugs to Gabapentinoids

If you’ve been taking dopaminergic drugs for a long time, your doctor may now recommend switching you to gabapentinoids in light of the new guidelines. “Educating patients about their lower risk of augmentation [with gabapentinoids] and long-term efficacy of medication outcomes is vital,” says Devnani.

However, abruptly stopping dopamine medications can produce withdrawal symptoms. “To minimize this side effect, it’s often recommended that we introduce the new medication while the patients are still using their dopamine-type drugs. Patients are instructed to slowly wean off the dopamine medications over time (four to six weeks),” says Dr. Avidan.

“Another suggestion is to introduce the gabapentinoids medication to an effective dose before tapering off the dopaminergic medication. Dopamine agonist tapering, done slowly over the course of a month, is generally well-tolerated and successful,” says Avidan. “My experience shows that in some patients, complete discontinuation of the dopaminergic medication may not always be possible.”

Devnani adds that opioids may be used carefully during the weaning process to manage any breakthrough symptoms. It’s also very important to schedule regular follow-ups to monitor symptoms or side effects during this time.

“The new information on supplementing patients with iron deficiency is very important,” says Avidan. “Iron may be administered intravenously or by mouth. Patients take ferrous sulfate at a dose of 325 milligrams once a day or once every other day together with a glass of orange juice or vitamin C to improve absorption at bedtime.”

“New data shows that IV iron supplementation is extremely effective and can be particularly helpful for people with chronic iron deficiency,” adds Avidan.

But talk to your doctor before taking iron supplements, Dr. Cline says. “Nobody should start taking iron unless your doctor says it’s a good thing to do.”

• Dipyridamole, an antiplatelet (anticlotting) medication, may help alleviate symptoms. “It’s perhaps premature to generalize whether this medication may benefit most people with RLS in clinical practice,” says Avidan. More data are needed, but anecdotal evidence so far suggests that the treatment may have value for people with RLS.
• Extended-release opioids, such as oxycodone and hydrocodone, may also help ease severe RLS, according to the new guidelines. Opioids are a class of addictive, pain-relieving medication. Considering their serious risks of misuse and dependency, these drugs need to be carefully considered when treating RLS.
• Peroneal nerve stimulation is a treatment that affects the peroneal nerve that supplies the leg. The treatment works by “sending mild electric signals and stimulating the nerve fibers that are often involved in the setting of restless leg syndrome,” says Avidal. “Some patients with restless leg syndrome don’t like the side effects of medications, particularly when their symptoms are not severe. PNS treatment might offer these patients subjective improvement,” says Avidan.

Cline suggests keeping a diary to look for possible connections between what you do during the day and episodes of RLS symptoms once the evening rolls around. Did you drink coffee too late in the afternoon, or did you stay seated all day at the office? If you can identify triggers, you may be able to make changes to avoid them.

Strategies include:

• Cutting Back on Caffeine, Alcohol, and Nicotine Try to limit drinking, smoking, and sipping coffee and other caffeinated drinks during the day. These are all substances that may make your RLS symptoms worse, according to the RLS Foundation.

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   Research shows that nonsmokers who limit their alcohol consumption have a lower risk of developing RLS.

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• Exercising Sitting still for too long can trigger RLS symptoms, so making time for daily exercise is a good idea. Regular exercisers are more than 3 times less likely to have RLS than non-exercisers, according to the RLS Foundation. But exercising too close to bedtime is not a good idea, as it can overstimulate the brain and worsen symptoms.

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• Maintaining Good Sleep Hygiene The RLS Foundation also recommends maintaining good sleeping habits, like avoiding technology before bed, sticking to a consistent schedule, and cultivating a relaxing evening ritual before bed.

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• Using Heat and Massage Cline recommends massaging your legs and taking hot baths to prevent and alleviate RLS symptoms. A meta-analysis published in April 2022 found that massage relieved the severity of symptoms without increasing the risk of adverse events.

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In addition to medication and lifestyle changes, there’s some evidence that alternative therapies, including those below, may be helpful.

• Pneumatic Pressure Therapy Pressure compression devices are cuffs you put on your legs that gently squeeze them to increase blood flow. Boosting circulation may help ease the uncomfortable RLS sensations.

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• Acupuncture An analysis of 18 studies looking at acupuncture for the treatment of RLS symptoms found it to be an effective option.

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   Another study found that patients treated with acupuncture along with a low dose of gabapentin had significantly better sleep than those who were treated with gabapentin alone.

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• Stress Management Whether you’re stretching, meditating, or practicing yoga, take time to de-stress. This may help you sleep better overall and settle the mind before bed.

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Diagnosing and managing RLS in children comes with unique challenges. “One of the biggest challenges is that many children who experience restless legs may have difficulties verbalizing what they experience,” says Avidan.

Devnani and Avidan explain that RLS is often confused with growing pains, leg cramps, attention deficit hyperactivity disorder (ADHD), or behavioral issues in children.

To prevent misdiagnosing a child with RLS, “we conduct a sleep study where we monitor for leg movements,” says Avidan.

Another challenge is that there isn’t enough clinical data on the safety and effectiveness of certain medications. “There are no good clinical trials looking at the safety and efficacy of specific medications for restless legs in children, but it’s important to prevent iron deficiency,” Avidan says.

Devnani agrees: “When managing RLS in children, use of oral iron in cases of iron deficiency is a low-risk, accessible treatment that addresses the underlying cause. Be vigilant about noticing adverse effects such as constipation,” she adds.

• The first step in treating RLS is checking with your doctor to see if there are any medications or factors in your life that may be causing your symptoms.
• While there is no cure for RLS yet, there are many treatment options, ranging from medication to alternative therapies.
• New AASM treatment guidelines recommend against the long-term use of dopaminergic drugs to treat RLS, as they may worsen symptoms. Instead, the AASM recommends gabapentinoids.
• Iron supplementation remains key for treating and preventing RLS, especially in children; many people with RLS have an iron deficiency.