Treatments for Restless Legs Syndrome

Treatment of restless legs syndrome (RLS) depends somewhat on the frequency of symptoms and there are many options, including medications as well as lifestyle changes. For the purposes of selecting the appropriate treatment, you should determine if your symptoms are intermittent, daily, or refractory to treatment.

Lifestyle modifications should always be tried first. Sleep deprivation worsens RLS symptoms, hence good sleep hygiene is important. Strenuous exercise right before bed should be avoided. On the other hand, regular moderate exercise appears helpful. There are a number of prescription and over-the-counter medications that can contribute to RLS and their use should be reviewed by a healthcare practitioner to see if changes need to be made. There is a clear relationship between anemia and RLS, and treating the anemia can markedly improve the symptoms.

If these measures prove unhelpful, there are medications that can be tried, some FDA approved and some used off-label.

Dopamine Drugs

The first-line treatment for restless legs syndrome are drugs that can affect dopamine levels. This may be accomplished through direct dopamine replacement (with a drug called levodopa) or with medications that increase your intrinsic dopamine levels by changing how the body uses it. Levodopa has the potential for side effects, including nausea, lightheadedness, and drowsiness. In addition, levodopa can lead to augmentation, in which symptoms may occur earlier in the day, become more severe, or even spread to the arms. This can be treated by adding an earlier dose, but if it persists levodopa should be stopped or the dose lowered. Because of these difficulties, medications called dopamine agonists are often preferred.

Three of the four drugs approved by the FDA for treating RLS are dopamine agonists and include pramipexole (brand name Mirapex), rotigotine (brand name Neupro), and ropinirole (brand name Requip). These are less likely to cause side effects such as augmentation, although it can still happen. There may be some mild lightheadedness and fatigue, but this usually resolves after a few weeks of treatment. Less frequent side effects include nasal stuffiness, constipation, insomnia, and leg edema. In addition, there is the possibility of an increased risk of impulse control disorders which may involve pathologic gambling, compulsive eating or shopping, or inappropriate hypersexuality.

The FDA requires the insert of these medications to include that psychiatric adverse events are possible including mania, agitation, hallucinations, and psychosis. One study found first-time users of these drugs for RLS had twice the risk of experiencing a psychiatric event over the control group. There have been reports of people falling asleep during activities of daily living. They should be used with caution with people with heart, liver, or kidney disease.

There are three other less commonly used medications that can affect dopamine levels called bromocriptine, pergolide, and cabergoline. These are not used as often because of the rare (but potentially serious) complication of fibrosis (scarring) of the heart valves. Due to these complications, pergolide is not available in the United States. Cabergoline is not FDA-approved for RLS treatment, but it is sometimes used off-label for these purposes. It may cause nausea, constipation, headache, dizziness, fatigue, or drowsiness.

Opioids

Opioid medications are most often used to treat moderate to severe pain, but they can also be useful in the treatment of RLS. Some of the more common agents used include oxycodone, codeine, and methadone. They are generally given in divided doses throughout the day to suppress the RLS symptoms.

As opposed to opioid use in pain treatment, there is less risk of addiction (in individuals without a prior history of substance abuse), but tolerance can develop (where more medication is needed to get the same effect). Regular follow-up to monitor tolerance and efficacy is needed. Side effects can include constipation, depression, unsteadiness, nausea, and itching. As these drugs do modestly depress breathing, careful use is advised if you have sleep apnea. Opioids are usually only used in people who fail other treatments.

Gabapentin

If RLS symptoms occur daily or are resistant to other treatments, the use of gabapentin—the fourth drug approved for RLS, may be employed.Gabapentin is sometimes used to treat seizures or neuropathic pain, but it is also effective in RLS. It is given in divided doses throughout the day. It may, among other things, cause unsteadiness in walking, blurred or double vision, dizziness, fatigue, or swelling. It can be particularly effective if the pain is perceived with the RLS symptoms.

Benzodiazepines

The class of medications called benzodiazepines is often useful in mild cases of RLS, particularly among younger people. If you have intermittent symptoms, it may be a good choice. The most common agents include clonazepam and diazepam. The direct effect on leg discomfort is minimal, but it can improve sleep quality. These medications may cause unsteady gait, morning drowsiness, or slowed thinking.

Alternative Therapies for RLS

There are other lifestyle modifications that may be helpful in improving your RLS symptoms. These include stretching exercises before bedtime. In addition, keeping yourself mentally occupied during periods of boredom may decrease your symptoms. This may involve playing video games or doing crossword puzzles.

Finally, you should avoid factors that may exacerbate your RLS symptoms. Caffeine, nicotine, and alcohol may all worsen your symptoms. Moreover, some antidepressants, antiemetics such as metoclopramide, and antihistamines should also be avoided as they may aggravate RLS.

Lavender, an essential oil, has some sedating and calming effects that might help RLS. A study published in 2015 tested this, using a massage oil infused with lavender to treat people with chronic renal failure and RLS (a common problem among dialysis patients). They found that the treated group (with the massage oil applied to the legs below the knee) had a significant improvement in their symptoms that was not seen in the control group.

A Word From Verywell

If symptoms of restless legs syndrome are bothering you, speak with your physician. In some cases, consultation with a neurologist or board-certified sleep physician may be necessary to find the right solution for you. Fortunately, relief can often be found with the use of medication.