Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Restless Legs Syndrome Treatment & Management

  • Author: Ali M Bozorg, MD; Chief Editor: Selim R Benbadis, MD  more...
 
Updated: Apr 15, 2016
 

Approach Considerations

Treatment for restless legs syndrome (RLS) may not be necessary for patients with mild or sporadic symptoms or for those without significant impairment.[4] Treatment should be tailored to the patient’s specific symptoms and may involve pharmacotherapy and nonpharmacologic measures.[4] Patients should be monitored by a neurologist or their primary care provider for development of adverse events, augmentation, or rebound.

In 2014, the US Food and Drug Administration (FDA) gave commercial clearance to the first device (Relaxis) for improvement of sleep quality in patients with primary RLS. The device, a vibrating pad, delivers vibratory counterstimulation to the patient’s legs as an individual lies in bed. Approval was based on 2 randomized studies that showed greater improvements in sleep quality with the device than with a placebo pad.[37]

Next

Pharmacologic Therapy

Drug therapy for primary RLS is largely symptomatic; cure is possible only for secondary RLS. In some patients, RLS symptoms occur sporadically, with spontaneous remissions lasting weeks or months. The use of pharmacotherapy on an irregular basis is warranted in such cases. Continuous pharmacologic treatment should be considered if patients complain of having RLS symptoms at least 3 nights each week.

Medications used in the treatment of restless legs syndrome (RLS) include the following:

  • Dopaminergic agents (eg, pramipexole, [25] ropinirole, [26, 27] bromocriptine, levodopa-carbidopa, and rotigotine [28] )
  • Benzodiazepines (eg, clonazepam)
  • Opioids (eg, codeine)
  • Anticonvulsants (eg, gabapentin [29] and pregabalin)
  • Presynaptic alpha 2 -adrenergic agonists (eg, clonidine)
  • Iron salt

A Task Force of the International Restless Legs Syndrome Study Group (IRLSSG) has developed evidence-based guidelines for long-term pharmacologic treatment of RLS.[30] The Task Force reviewed the results of 61 studies and arrived at the following conclusions with respect to available medications:

· Pregabalin - Effective for up to 1 year in treating RLS (evidence level, A).

· Pramipexole, ropinirole, and rotigotine - Effective for up to 6 months in treating RLS (evidence level, A)

· Gabapentin enacarbil (1 year), pramipexole (1 year), ropinirole (1 year), levodopa (2 years), and rotigotine (5 years) - Probably effective in treating RLS for durations ranging from 1 to 5 years (evidence level, B)

· Pergolide and cabergoline - Because of associated safety concerns, not to be used in treating RLS unless the benefits clearly outweigh the risks

The IRLSSG Task Force recommends either a dopamine-receptor agonist or an alpha2-delta calcium-channel ligand as first-line treatment therapy for RLS in most patients, with the choice of medication depending on symptom severity, cognitive status, history, and comorbid conditions.[30]

All patients with low iron levels (ferritin < 50 ng/mL) should receive supplemental iron therapy.[4] In iron deficiency, 325 mg of ferrous sulfate may be given with 250 mg of vitamin C. Absorption is increased by taking this on an empty stomach and waiting 60 minutes before eating. Parenteral iron may also have a role in the treatment of RLS secondary to iron deficiency anemia.[31]

Anecdotal evidence from Japan suggests that yokukansan (an herbal remedy) may be effective in the treatment of RLS.[32] Oral corticosteroids have also been used to treat RLS in exceptional circumstances.[33] Currently, steroids and yokukansan are not approved by the US Food and Drug Administration (FDA) as therapy for RLS.

No specific recommendations or FDA-approved medications exist for the treatment of RLS in children. Children with low serum ferritin (< 50 ng/mL) should be treated with supplemental iron therapy. Dopaminergic therapy was found to be effective in small series in children with RLS.

Previous
Next

Nonpharmacologic Therapy

Sleep hygiene measures should be recommended to all patients. Moreover, patients with mild RLS who are sensitive to caffeine, alcohol, or nicotine should avoid these substances. Offending medications (eg, selective serotonin reuptake inhibitors [SSRIs], diphenhydramine, and dopamine antagonists) also should be discontinued when it is possible to do so.

Exercise may be helpful for some patients[34] ; however, this potential benefit has not been systematically studied. In general, physical measures are only partially or temporarily helpful and should be avoided before bedtime. Some patients benefit from different physical modalities before bedtime, such as a hot or cold bath, a whirlpool bath, limb massage, or vibratory or electrical stimulation of the feet and toes.

Nonpharmacologic management and sleep hygiene measures are the treatments of choice in children. A regular sleep/wake schedule and the elimination of stimulating activity and caffeine before bedtime are important measures.

Previous
 
 
Contributor Information and Disclosures
Author

Ali M Bozorg, MD Assistant Professor, Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida College of Medicine

Ali M Bozorg, MD is a member of the following medical societies: American Academy of Neurology, American Epilepsy Society, American Academy of Sleep Medicine

Disclosure: Received honoraria from Cyberonics for speaking and teaching; Received honoraria from UCB, Inc. for speaking and teaching.

Chief Editor

Selim R Benbadis, MD Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, Tampa General Hospital, University of South Florida College of Medicine

Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Medical Association, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cyberonics; Eisai; Lundbeck; Sunovion; UCB; Upsher-Smith<br/>Serve(d) as a speaker or a member of a speakers bureau for: Cyberonics; Eisai; Glaxo Smith Kline; Lundbeck; Sunovion; UCB<br/>Received research grant from: Cyberonics; Lundbeck; Sepracor; Sunovion; UCB; Upsher-Smith.

Acknowledgements

Jose E Cavazos, MD, PhD, FAAN Associate Professor with Tenure, Departments of Neurology, Pharmacology, and Physiology, Program Director of the Clinical Neurophysiology Fellowship, University of Texas School of Medicine at San Antonio; Co-Director, South Texas Comprehensive Epilepsy Center, University Hospital System; Director of the San Antonio Veterans Affairs Epilepsy Center of Excellence and Neurodiagnostic Centers, Audie L Murphy Veterans Affairs Medical Center

Jose E Cavazos, MD, PhD, FAAN is a member of the following medical societies: American Academy of Neurology, American Clinical Neurophysiology Society, American Epilepsy Society, and American Neurological Association

Disclosure: GXC Global, Inc. Intellectual property rights Medical Director - company is to develop a seizure detecting device. No conflict with any of the Medscape Reference articles that I wrote or edited.

William G Irr, MD Consulting Staff, Department of Neurology Service, St Luke's Episcopal Hospital of Houston

William G Irr, MD is a member of the following medical societies: American Academy of Neurology.

Disclosure: Nothing to disclose.

Juan Latorre, MD Research Fellow, Department of Physical Medicine and Spinal Cord Injury Medicine, The Institute for Rehabilitation and Research

Juan Latorre, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation

Disclosure: Nothing to disclose.

Erasmo A Passaro, MD, FAAN Director, Comprehensive Epilepsy Program/Clinical Neurophysiology Lab, Bayfront Medical Center, Florida Center for Neurology

Erasmo A Passaro, MD, FAAN is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, American Medical Association, and American Society of Neuroimaging

Disclosure: Glaxo Smith Kline Honoraria Speaking and teaching; UCB Honoraria Speaking and teaching; Pfizer Honoraria Speaking and teaching; Forest Honoraria Speaking and teaching

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Reference Salary Employment

References
  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. 5th. Arlington, VA: American Psychiatric Association; 2013. 410-3.

  2. Krueger BR. Restless legs syndrome and periodic movements of sleep. Mayo Clin Proc. 1990 Jul. 65(7):999-1006. [Medline].

  3. Gamaldo CE, Earley CJ. Restless legs syndrome: a clinical update. Chest. 2006 Nov. 130(5):1596-604. [Medline].

  4. Hening WA. Restless Legs Syndrome. Curr Treat Options Neurol. 1999 Sep. 1(4):309-319. [Medline].

  5. Ferreri F, Rossini PM. Neurophysiological investigations in restless legs syndrome and other disorders of movement during sleep. Sleep Med. 2004 Jul. 5(4):397-9. [Medline].

  6. Restless legs syndrome. detection and management in primary care. National Heart, Lung, and Blood Institute Working Group on Restless Legs Syndrome. Am Fam Phys. 2000 Jul 1. 62(1):108-14. [Medline].

  7. Evidente VG, Adler CH. How to help patients with restless legs syndrome. Discerning the indescribable and relaxing the restless. Postgrad Med. 1999 Mar. 105(3):59-61, 65-6, 73-4. [Medline].

  8. Silber MH. Restless legs syndrome. Mayo Clin Proc. 1997 Mar. 72(3):261-4. [Medline].

  9. Takaki J, Nishi T, Nangaku M, et al. Clinical and psychological aspects of restless legs syndrome in uremic patients on hemodialysis. Am J Kidney Dis. 2003 Apr. 41(4):833-9. [Medline].

  10. Walters AS, LeBrocq C, Dhar A, et al. Validation of the International Restless Legs Syndrome Study Group rating scale for restless legs syndrome. Sleep Med. 2003 Mar. 4(2):121-32. [Medline].

  11. Weinstock LB, Walters AS, Paueksakon P. Restless legs syndrome - Theoretical roles of inflammatory and immune mechanisms. Sleep Med Rev. 2012 Jan 16. [Medline].

  12. Winkelman JW. Considering the causes of RLS. Eur J Neurol. 2006 Oct. 13 Suppl 3:8-14. [Medline].

  13. Allen RP, Earley CJ. Restless legs syndrome: a review of clinical and pathophysiologic features. J Clin Neurophysiol. 2001 Mar. 18(2):128-47. [Medline].

  14. Jhoo JH, Yoon IY, Kim YK, Chung S, Kim JM, Lee SB. Availability of brain serotonin transporters in patients with restless legs syndrome. Neurology. 2010 Feb 9. 74(6):513-8. [Medline].

  15. Trenkwalder C, Hogl B, Winkelmann J. Recent advances in the diagnosis, genetics and treatment of restless legs syndrome. J Neurol. 2009 Apr. 256(4):539-53. [Medline].

  16. Cesnik E, Casetta I, Turri M, Govoni V, Granieri E, Strambi LF, et al. Transient RLS during pregnancy is a risk factor for the chronic idiopathic form. Neurology. 2010 Dec 7. 75(23):2117-20. [Medline].

  17. Berger K, Luedemann J, Trenkwalder C, et al. Sex and the risk of restless legs syndrome in the general population. Arch Intern Med. 2004 Jan 26. 164(2):196-202. [Medline].

  18. Kutner NG, Zhang R, Huang Y, Bliwise DL. Racial differences in restless legs symptoms and serum ferritin in an incident dialysis patient cohort. Int Urol Nephrol. 2012 Jan 5. [Medline].

  19. Abetz L, Allen R, Follet A, et al. Evaluating the quality of life of patients with restless legs syndrome. Clin Ther. 2004 Jun. 26(6):925-35. [Medline].

  20. Ekbom K, Ulfberg J. Restless legs syndrome. J Intern Med. 2009 Nov. 266(5):419-31. [Medline].

  21. Simakajornboon N, Kheirandish-Gozal L, Gozal D. Diagnosis and management of restless legs syndrome in children. Sleep Med Rev. 2009 Apr. 13(2):149-56. [Medline].

  22. Kotagal S, Silber MH. Childhood-onset restless legs syndrome. Ann Neurol. 2004 Dec. 56(6):803-7. [Medline].

  23. Lane RM. SSRI-induced extrapyramidal side-effects and akathisia: implications for treatment. J Psychopharmacol. 1998. 12(2):192-214. [Medline].

  24. Hattan E, Chalk C, Postuma RB. Is there a higher risk of restless legs syndrome in peripheral neuropathy?. Neurology. 2009 Mar 17. 72(11):955-60. [Medline].

  25. Montplaisir J, Nicolas A, Denesle R. Restless legs syndrome improved by pramipexole: a double-blind randomized trial. Neurology. 1999 Mar 23. 52(5):938-43. [Medline].

  26. Ondo W. Ropinirole for restless legs syndrome. Mov Disord. 1999 Jan. 14(1):138-40. [Medline].

  27. Giorgi L, Asgharian A, Hunter B. Ropinirole in Patients With Restless Legs Syndrome and Baseline IRLS Total Scores =24: Efficacy and Tolerability in a 26-Week, Double-Blind, Parallel-Group, Placebo-Controlled Study Followed by a 40-Week Open-Label Extension. Clin Ther. 2013 Aug 9. [Medline].

  28. Baldwin CM, Keating GM. Rotigotine transdermal patch: in restless legs syndrome. CNS Drugs. 2008. 22(10):797-806. [Medline].

  29. Bogan RK, Bornemann MA, Kushida CA, Trân PV, Barrett RW. Long-term maintenance treatment of restless legs syndrome with gabapentin enacarbil: a randomized controlled study. Mayo Clin Proc. 2010 Jun. 85(6):512-21. [Medline]. [Full Text].

  30. Garcia-Borreguero D, Kohnen R, Silber MH, Winkelman JW, Earley CJ, Högl B, et al. The long-term treatment of restless legs syndrome/Willis-Ekbom disease: evidence-based guidelines and clinical consensus best practice guidance: a report from the International Restless Legs Syndrome Study Group. Sleep Med. 2013 Jul. 14(7):675-84. [Medline].

  31. Grote L, Leissner L, Hedner J, Ulfberg J. A randomized, double-blind, placebo controlled, multi-center study of intravenous iron sucrose and placebo in the treatment of restless legs syndrome. Mov Disord. 2009 Jul 30. 24(10):1445-52. [Medline].

  32. Shinno H, Yamanaka M, Ishikawa I, Danjo S, Nakamura Y, Inami Y. Successful treatment of restless legs syndrome with the herbal prescription Yokukansan. Prog Neuropsychopharmacol Biol Psychiatry. 2010 Feb 1. 34(1):252-3. [Medline].

  33. Oscroft NS, Smith IE. Oral glucocorticosteroids: effective in a case of restless legs syndrome resistant to other therapies. Sleep Med. 2010 Jun. 11(6):596. [Medline].

  34. Giannaki CD, Hadjigeorgiou GM, Karatzaferi C, Maridaki MD, Koutedakis Y, Founta P, et al. A single-blind randomized controlled trial to evaluate the effect of 6 months of progressive aerobic exercise training in patients with uraemic restless legs syndrome. Nephrol Dial Transplant. 2013 Aug 8. [Medline].

  35. Anderson P. Restless Legs Syndrome Linked to Higher Mortality. Available at http://www.medscape.com/viewarticle/805712. Accessed: Jun 19 2013.

  36. Li Y, Wang W, Winkelman JW, Malhotra A, Ma J, Gao X. Prospective study of restless legs syndrome and mortality among men. Neurology. 2013 Jun 12. [Medline].

  37. Jeffrey S. FDA Okays First Device for Restless Legs Syndrome. Medscape Medical News. May 30 2014. [Full Text].

 
Previous
Next
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.