Restless Legs Syndrome

What is restless legs syndrome?

Restless legs syndrome (RLS) is a neurological condition characterized by an unpleasant urge to move the legs that occurs mainly at rest and in the evening/at night. RLS is one of the most common neurological conditions and affects about 5–10% of the population.

Symptoms

  • Unpleasant urge to move the legs, less often also the arms
  • Abnormal sensations: tingling, pulling, tearing, burning deep in the legs
  • Symptoms occur at rest (sitting, lying down) and improve with movement
  • Worsening in the evening and at night
  • Difficulty falling asleep and staying asleep
  • Periodic limb movements during sleep (PLMS)
  • Daytime tiredness and exhaustion as a result of disturbed sleep

Causes

Primary (idiopathic) RLS

  • Most common form, often familial clustering
  • Genetic predisposition (several risk genes identified)
  • Disturbance of dopamine metabolism in the brain

Secondary RLS

  • Iron deficiency – most common treatable cause (the ferritin value can be too low even with normal hemoglobin)
  • Kidney insufficiency – especially in dialysis patients
  • Pregnancy – temporary, usually resolving after birth
  • Polyneuropathy – can trigger or worsen RLS symptoms
  • Medications – antidepressants (SSRIs), neuroleptics, antihistamines can worsen RLS

Diagnostics

  • Detailed medical history – the diagnosis is made clinically based on the typical symptoms
  • Neurological examination – to rule out polyneuropathy
  • Laboratory tests – ferritin (iron stores), transferrin saturation, kidney values, thyroid values, vitamin B12
  • Nerve conduction velocity (NCV) – when accompanying polyneuropathy is suspected
  • Polysomnography if needed – sleep laboratory examination in unclear cases (referral)

Treatment

Treatment of the cause

  • Iron supplementation when ferritin is below 75 µg/l (oral or intravenous)
  • Discontinuing or switching medications that worsen RLS
  • Treatment of an underlying condition (kidney insufficiency, polyneuropathy)

Drug therapy

  • Iron supplementation (oral or intravenous) – a first-line option according to current guidelines (incl. AASM 2024): the ferritin value is checked first; symptoms often improve simply by replenishing the iron stores
  • Gabapentinoids / alpha-2-delta ligands (Gabapentin, Pregabalin) – also first-line, especially for painful RLS and accompanying sleep disturbances
  • Dopamine agonists (e.g. Pramipexole, Rotigotine patch) – now only second-line, because long-term use frequently leads to augmentation (paradoxical worsening: symptoms start earlier in the day and become more intense)
  • L-Dopa – only for intermittent symptoms in low doses (risk of augmentation)
  • Opioids (e.g. Oxycodone/Naloxone) – for treatment-refractory RLS

Non-drug measures

  • Regular moderate exercise (no intense sport in the evening)
  • Sleep hygiene (regular sleep times, cool bedroom)
  • Avoiding caffeine and alcohol in the evening
  • Leg massages, alternating hot and cold showers

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Last updated: 2026-07-22