Patient information · Neurology
Restless legs syndrome
check the iron before anything else
Restless legs syndrome is an irresistible urge to move the legs, with unpleasant sensations that come on at rest and in the evening and are relieved by movement. It is common, frequently dismissed, and in a substantial proportion of people it is caused by low iron stores — which is correctable.
Arrange assessment if you also have
- numbness, weakness or loss of sensation in the legs
- leg pain on walking that eases with rest — this suggests circulation, not restless legs
- swelling, redness or warmth of one calf
- symptoms in pregnancy, which need a different approach
- severe daytime sleepiness, or falling asleep while driving
- restless legs with kidney disease or on dialysis
Peripheral neuropathy, peripheral arterial disease, deep vein thrombosis and nocturnal leg cramps all cause leg symptoms at night and are distinct conditions. If you are falling asleep during the day, do not drive until it has been assessed.
The five features
All five are needed for the diagnosis:
- an urge to move the legs, usually with uncomfortable sensations — crawling, fizzing, aching, an electric feeling
- beginning or worsening during rest or inactivity
- partially or completely relieved by movement, at least while moving
- worse in the evening or at night
- not better explained by another condition
Ferritin should be above 75, not just 'normal'
Iron in the brain matters here even when blood counts are normal. A ferritin reported as within the laboratory range can still be too low for restless legs, and the treatment target is a ferritin above 75 micrograms/L with transferrin saturation above 20% — considerably higher than the usual lower limit. Correcting iron to that level substantially improves or resolves symptoms in many people, and it should be checked before any medication is started. Ask for the actual number rather than accepting 'normal'.
Things that make it worse
- Medicines — sedating antihistamines (including in cold and sleep remedies), most antidepressants, antipsychotics, metoclopramide and prochlorperazine. Reviewing these is often the single most useful step.
- Caffeine, alcohol and nicotine, particularly in the evening.
- Sleep deprivation, which worsens symptoms and is worsened by them.
- Pregnancy, particularly the third trimester — usually resolving after delivery.
- Kidney disease and dialysis.
- Some people find intense exercise late in the evening aggravates it.
Self-management
Helps
- Moderate regular exercise, earlier in the day
- A consistent sleep schedule, and a cool bedroom
- Stretching, walking, or a warm or cool bath before bed
- Massage, and counter-stimulation such as a weighted blanket
- Mental activity during unavoidable sitting — long flights, cinema
Worth reviewing
- Evening caffeine, alcohol and nicotine
- Antihistamines in over-the-counter sleep aids
- Antidepressants, if the timing fits — ask before changing anything
- Very late intense exercise
- Long periods of enforced sitting without a plan
Medication
- Correct the iron first. Oral iron, or intravenous iron where absorption is poor or the need is urgent.
- Alpha-2-delta ligands — gabapentin or pregabalin — are now generally preferred as first-line drug treatment.
- Dopamine agonists are effective but are used more cautiously than they once were, because of augmentation: symptoms starting earlier in the day, spreading to the arms and becoming more intense over months or years. It is caused by the treatment, it is common with long-term use, and it is difficult to reverse. If your symptoms have worsened on a dopamine agonist, that is a reason to be reviewed, not to increase the dose.
- Impulse control problems — gambling, compulsive shopping or eating — are a recognised and under-reported effect of dopamine agonists. Tell us if anything like this has changed.
Why come to us. Restless legs is routinely dismissed as a quirk, and the one test that matters is frequently not done or not interpreted properly. We check ferritin, transferrin saturation, full blood count, kidney and thyroid function in-house, tell you the actual numbers against the right targets, review every medicine you take for the ones that aggravate it, and prescribe appropriately — including recognising augmentation if you are already on treatment. Seven days a week.
Ferritin checked against the right target, not just 'normal'
Bloods in-house with the numbers explained. Seven days a week.
Tower Bridge Hospital London
97–99 Whitechapel Road, London E1 1DT
WhatsApp 07903 284 189
info@mhwclinic.co.uk
Open Mon–Sat, 9am–7pm (closed Sundays until September)
In an emergency
Call 999, or go to the Royal London Hospital Emergency Department, Whitechapel Road, London E1 1FR.
When we are closed and it is not an emergency
Call NHS 111 or visit 111.nhs.uk.