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. In general, those with intermittent symptoms should use lifestyle modifications, medications that affect dopamine levels, low dose opioids, or benzodiazepines. If symptoms are daily, gabapentin may be a useful additional option. Finally, if you have symptoms that are not responsive to medications, you may need to try a different or even a second medication.
The first-line treatment for restless legs syndrome are the 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, light-headedness, 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, the medications called dopamine agonists are often preferred.
The dopamine agonists include medications such as pramipexole (brand name Mirapex) and ropinirole (brand name Requip). These are less likely to cause side effects such as augmentation. 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.
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.
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 surprisingly little risk of addiction or tolerance when it is used to treat RLS. Constipation may occur, but it is typically minor. As these drugs do modestly depress breathing, careful use is advised if you have sleep apnea. The opioids are usually only used in people who fail other treatments.
If RLS symptoms occur daily or are resistant to other treatments, the use of gabapentin 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 cause unsteadiness in walking or drowsiness. It can be particularly effective if pain is perceived with the RLS symptoms.
The class of medications called benzodiazepines are 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
If you are found to be iron deficient upon initial evaluation of the cause of your RLS symptoms, iron replacement may be a useful therapy. It generally should not be used as your sole treatment, however. With the use of oral iron supplements, vitamin C can be helpful to improve absorption.
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.
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Silber, MH et al. “An algorithm for the management of restless legs syndrome.” Mayo Clin Proc 2004; 79:916.
Waters, AS. “Restless legs syndrome and periodic limb movements in sleep.” Continuum. Neurol 2007; 13(3):115-138.