Dr. Nitun Verma is the leading sleep medicine physician in the San Francisco Bay Area, director of the Washington Township Center for Sleep Disorders in Fremont, California, and author of the Epocrates.com guide for RLS.
What is the most likely cause of my signs and symptoms?
Currently it is believed that the cause is a low level of a neurotransmitter called dopamine that uses iron as a building block. Lower levels of dopamine, or medications that lower it, cause the classic symptoms of uncomfortable feelings in the legs (sometimes arms) most often in the evening.
Are there any other possible causes?
Other causes can be pregnancy, certain antidepressants, antihistamines such as Benadryl, and kidney failure. RLS has a genetic component—it tends to run in families.
What treatment options are available?
The first and often best option is massage. Massaging the legs every evening helps prevent symptoms most of the time. Massage before sleep helps. I recommend it as a first-line treatment before considering medications. Warm compresses or cold compresses may help. My patients who use electric massages (like the ones for back pain) get great benefits.
The next step is to swap out medications that can worsen symptoms such as certain antidepressants and antihistamines. If your doctor finds that you have low levels of iron, replacing it can help, too. The last resort is using medications made to treat restless
legs, and the good news is that there has been progress in finding new medications.
Are there any nutritional supplements that might help?
If you are low in iron, a good supplement would be iron for a few months to see if that helps. Iron can cause GI upset, though, so I only recommend it for people who are low in iron. Magnesium is being studied right now as a treatment, but there isn’t enough data to offer it as an official treatment.
What medications do you usually recommend? What are the possible side effects?
Dopamine medication can help, but can occasionally have the side effect of the body getting used to it if taken at high doses. Another class of medication is related to gabapentin, a medication historically used for seizures. There are some new medications such as Neupro, a dopamine patch you place on your skin instead of swallowing as a pill. Horizant is a new gabapentin/neurontin-related medication that needs less adjusting of doses compared to older medications.
Pain relievers don’t work for RLS. If they help, you probably have something else. I have had many people take over-the-counter sleep aids. Benadryl is an ingredient in most of these treatments and makes RLS symptoms worse. Then they take even higher doses and it sets off a bad spiral. Other medications that make it worse: dopamine antagonists, lithium carbonate, antidepressants such as tricyclics, SSRIs (Paxil, Prozac, etc.). Wellbutrin (buproprion) is an antidepressant that is an exception and has not been
shown to increase symptoms of RLS.
I have these other health conditions. How can I best manage them together?
If you also have depression, you may be on a medication that worsens RLS symptoms. Don’t stop it by yourself, but ask your doctor if another kind of antidepressant can work instead. Buproprion is an antidepressant that can help RLS symptoms in some cases.
People with RLS don’t sleep as much, and less sleep is linked to depression, diabetes, and high blood pressure. But it is hard to treat high blood pressure without addressing the sleep problem, too. Unfortunately, sleep is often ignored in these patients.
What self-care steps are likely to improve my symptoms?
The best self-care step is massaging your legs nightly. If you find that the symptoms start at a certain time, like say 9 p.m., then massage between 8 and 9 p.m. Sometimes massaging before the symptoms start can work best.
Does exercise help? What kind is best?
Exercises involving the affected muscles are best, but they shouldn’t be too strenuous. Even walking and stretching will be good enough.
Do you have any websites you recommend where I can get more information? Where can I find a support group for people with restless legs syndrome?
www.sleepeducation.org is a great site run by the American Academy of Sleep Medicine that has information on RLS. It can help point you to a local support group.