Restless Legs Syndrome: Symptoms, Causes and Treatment

Restless legs syndrome (RLS) is a sleep and nerve condition that causes a strong urge to move your legs, usually with uncomfortable feelings in them. It starts or gets worse when you rest, eases when you move, and is worst in the evening and at night. Checking iron levels is a key first step, because low iron is a common and treatable cause.

Symptoms: the URGE checklist

RLS is also called Willis-Ekbom disease. Doctors diagnose it from a set of signs that all have to be present.^[1] An easy way to remember them is the word URGE:

• U — Urge to move — a strong need to move the legs, often with feelings like crawling, tingling, pulling, aching or "electric" sensations deep in the legs.
• R — Rest makes it worse — it starts or gets worse when sitting or lying still, such as in the car, at the movies or in bed.
• G — Gets better with movement — walking or stretching eases it, at least while you keep moving.
• E — Evening and night — symptoms are worse later in the day or only happen then.

The doctor also checks that another problem, such as leg cramps, joint pain, swelling or simply an uncomfortable position, does not fully explain the feelings.^[1] Many people with RLS also have small, repeated leg jerks during sleep called periodic limb movements.

Causes and triggers

In many people there is no single cause, and RLS often runs in families. Some things can bring it on or make it worse:^[2]

• Low iron — the brain needs iron to manage dopamine, a chemical involved in movement. Iron stores can be low for RLS even when a standard blood count looks normal.
• Pregnancy — RLS is common in pregnancy, and treatment choices need to be safe for the baby.
• Kidney disease — RLS is more common in people with kidney failure and on dialysis.
• Some medicines — sedating antihistamines (in many sleep aids and allergy pills), many antidepressants, and medicines that block dopamine, such as some anti-nausea and antipsychotic medicines.
• Alcohol, caffeine and untreated sleep apnea — all can make symptoms worse.

Do not stop a prescribed medicine on your own. Ask your doctor whether it could be playing a role.

Restless legs in children

RLS is not just an adult problem. In a large survey of families, about 2 in 100 children and teens met the criteria for RLS, and most of them had a parent with symptoms.^[3] Children often describe it in their own words, like "itchy," "wiggly" or "bugs in my legs."

• Growing pains or RLS? — Growing pains are leg aches, often in the evening, without a strong urge to move. RLS comes with that urge and gets better when the child moves. Our article on growing pains in children covers the usual signs. Children with RLS were more likely to have been told they had growing pains, so the two can be confused.^[3]
• Possible ADHD link — Studies have found that RLS and ADHD show up together more often than expected.^[4] Poor sleep from RLS can also cause restlessness and trouble focusing in the daytime. The link is not fully understood, and RLS does not mean a child has ADHD. Our article on ADHD signs in children explains what to watch for.
• Iron matters in children too — for children with RLS, the guideline suggests iron when ferritin is below 50 ng/mL.^[2]

How RLS is diagnosed

There is no single test for RLS. The diagnosis comes from your description of symptoms, your health history and an exam.^[1] Blood tests are an important part of the visit:

• Iron studies — the 2024 American Academy of Sleep Medicine (AASM) guideline advises checking ferritin (stored iron) and transferrin saturation in everyone with clinically significant RLS, ideally in the morning and after at least 24 hours without iron pills or iron-rich foods.^[2]
• Other blood tests — such as kidney function, when the history suggests another cause.
• Sleep study, sometimes — not needed for most people, but useful when a doctor suspects sleep apnea or another sleep disorder.

Treatment: what the 2024 AASM guideline says

The AASM guideline, published in 2024, changed how doctors treat RLS.^[2] Treatment usually goes in steps:

• Remove triggers first — cut back on alcohol and caffeine, review medicines that can worsen RLS, and treat sleep apnea if present.
• Treat iron — in adults, iron is suggested when ferritin is 75 ng/mL or lower or transferrin saturation is under 20%. Oral or IV iron can be used, and IV iron alone when ferritin is between 75 and 100 ng/mL.^[2] These targets are higher than the usual ones for anemia.
• Gabapentin-type medicines — gabapentin, gabapentin enacarbil and pregabalin are strongly recommended.^[2] They can cause dizziness or sleepiness, especially at first.
• Dopamine medicines, with caution — pramipexole, ropinirole and the rotigotine patch were once first choice. The guideline now suggests against their standard use, because over time they can cause augmentation: symptoms that start earlier in the day, get stronger or spread to the arms.^[2] Some people may still choose them for short-term relief.
• Other options for some people — for hard-to-treat RLS, the guideline also suggests options such as low-dose opioids, dipyridamole or a leg-worn nerve stimulation device, chosen with a specialist.^[2]

If you already take a dopamine medicine and your symptoms are getting worse or starting earlier, talk with your doctor. Do not stop it suddenly on your own.

Lifestyle steps that may help

Healthy habits will not replace treatment, but they may ease symptoms for some people:^[5]

• Moderate daytime exercise — regular walking or stretching, not hard workouts late at night.
• Limit caffeine, alcohol and tobacco — especially in the afternoon and evening.
• Keep a regular sleep schedule — being overtired can make symptoms worse. Our sleep hygiene tips can help.
• Relax and distract — a warm bath, leg massage or a mentally engaging activity during long sits may help some people.

When to see a sleep specialist

Talk with a sleep doctor if:

• Leg feelings keep you from falling asleep — or wake you up, more than once in a while.
• You feel tired or moody during the day — from poor sleep at night.
• Your child has "growing pains" with an urge to move — or trouble sitting still at bedtime.
• Symptoms change on treatment — they start earlier, feel stronger or spread to the arms.

You can read more about how we evaluate RLS on our restless legs syndrome care page, and see other reasons to book in when to see a sleep specialist.

Restless legs care in Cedar Park

Dr. Minal Patel is board-certified in pediatrics and sleep medicine and evaluates restless legs syndrome in children and adults. The practice also offers in-lab and home sleep testing when another sleep disorder is suspected. We are accepting new patients by appointment, Monday through Friday, 8:30 to 5:00, and accept Medicaid and CHIP for sleep patients. We do not take walk-ins.