How to Sleep with Restless Legs Syndrome

Expert Insights from Dr. Luis Javier Peña-Hernández, MD, FCCP, a lung and sleep health specialist at PCSI, the largest integrated pulmonary and sleep disorder specialty group in Palm Beach County.

Restless Legs Syndrome (RLS), also called Willis-Ekbom disease, is a neurological condition that causes an urge to move your legs. It typically comes on at night just as you are relaxing and beginning to fall asleep. Everyone gets restless sometimes, but if you have RLS, you likely deal with this pain and discomfort most nights, and it can have a significant impact on your sleep quality. 

Thankfully, there are ways to deal with RLS. Lifestyle changes, medications, and the treatment of associated conditions can all help lessen the effect of RLS and get you a better, more comfortable night’s sleep. With the right solutions, you can fall asleep and stay asleep without feeling like your legs are ready to run a marathon without you.

Getting a Better Sleep with Restless Leg Syndrome

There are three basic ways doctors can help you treat your RLS. First, they look for an underlying condition and try to treat that. If your RLS isn’t associated with another condition or if you are treating that condition and still struggling with RLS, then doctors will try the second course of action: lifestyle changes. There are several small changes you can make to your lifestyle, which we’ll discuss more in the sections below. Finally, if these options are not effective, the doctor will prescribe medications specifically meant to relieve RLS symptoms.

Treating Conditions Related to RLS

How your doctor will go about treating conditions related to RLS depends on your doctor and your condition. If your RLS is related to your anxiety, for example, some doctors may recommend therapy and lifestyle changes, while others may prescribe an anti-anxiety medication. If you have both Parkinson’s and RLS, your doctor may be able to treat both conditions with one medicine. Both Parkinson’s and RLS are affected by dopamine levels, so a dopamine medication could help reduce both symptoms.

Treating RLS Through Lifestyle Changes 

RLS that is caused by a temporary medical condition or lifestyle choices may be resolved by altering certain daily activities and treating the underlying condition.

Here are some lifestyle changes to consider when treating RLS:

• Regular moderate exercise during the day: Strenuous exercise, especially within those last few hours before bed, is generally not a good idea for people with sleep disorders. But a small study found that moderate exercise in the middle of the day can significantly reduce RLS symptoms.

• Stress reduction or relaxation techniques: Even though RLS is a neurological disorder, some promising research suggests that psychological intervention could provide significant relief. A small study found that a 6-week mindfulness-based stress relief program resulted in a significant decrease in symptom relief and daytime sleepiness, and a significant increase in sleep quality.
• Use a comfortable mattress: Thus far, researchers haven’t found one specific type of mattress that is better for RLS symptoms, but according to the University of Michigan, sleeping on a mattress that’s comfortable for you is important for getting better sleep with RLS.

• Quit smoking and reduce or eliminate caffeine and alcohol: Smoking, caffeine, and alcohol all have the potential to make your RLS symptoms worse. According to one study, people who smoke are more likely to develop RLS in the first place, but other studies aren’t sure if quitting will actually help relieve symptoms. A case study found that nicotine’s effect on the brain’s dopamine production might help alleviate some people’s symptoms.

• However, experts agree that decreasing caffeine intake is definitely an important lifestyle change for managing RLS. Finally, research shows that alcohol increases nighttime waking, which causes more sleep disturbances on top of those caused by the RLS, and most RLS patients are advised to decrease or avoid alcohol use.

• Massage your legs: In addition to simply feeling nice, massage has been clinically proven to help reduce RLS symptoms. According to one study, the combination of massage and lavender essential oil helps significantly reduce RLS symptoms.

Treating RLS Through Supplements 

Some over-the-counter supplements may also help treat your RLS when it appears to be caused by certain deficiencies. 

Some of these supplements include: 

• Iron supplements when the patient has iron-deficiency anemia.
• Vitamin D when the patient demonstrates a Vitamin D deficiency.
• Vitamins C and E for patients on dialysis.
• Magnesium – especially when a magnesium deficiency is believed to contribute to the condition. Magnesium is believed to help regulate nerves and muscles. When magnesium levels are low, calcium can activate nerves and trigger muscle contractions.

 Always consult with your doctor before starting any treatment regimen to determine if your RLS is caused by a deficiency and to target that deficiency properly.  

Alternative RLS Treatments 

It is important to note that there are other ways to provide relief for RLS aside from taking a pill or supplementing. Some of these tactics include: 

• A foot wrap called restiffic applies pressure to certain points on the bottom of your feet. The pressure points send signals to the brain to relax the muscles. According to a study done on the effects of restiffic, patients who used it saw a significant decrease in symptom severity in just 24 hours, and their symptoms continued to decline the longer they used it.
• Pneumatic compression sleeves fit over your legs, inflating and deflating to provide and release gentle pressure; this increases blood flow, and several studies have shown that pneumatic compression sleeves improve quality of life, decrease sleepiness and fatigue, and continue to reduce symptoms long-term.
• Near-infrared spectroscopy (NIRS) uses long-wavelength light beams to penetrate the skin and increase circulation to help relieve RLS symptoms. Multiple studies show that 30-minute treatments three times a week significantly reduce symptoms when compared to symptom severity before treatment.
• Acupuncture has been shown to reduce the symptoms of RLS significantly. Acupuncture is part of Traditional Chinese Medicine (TCM), and many studies have demonstrated its effectiveness in several areas of medicine. When it comes to RLS specifically, there are several limited studies that demonstrate acupuncture’s ability to reduce symptoms and improve sleep quality even better than Western medications typically prescribed for RLS.

Prescription Medication Treatment for RLS

When behavioral adaptations and other drug-free remedies fail to relieve RLS symptoms, you may need prescription medication. If you feel that non-prescription options aren’t helping, be sure to consult your doctor about your medication options.

• The first-line treatment for RLS is often the dopaminergic drugs pramipexole, ropinirole, and rotigotine, which promote the release of dopamine to your brain. Dopamine is involved in purposeful muscle movements, and some RLS patients experience symptoms as a result of a dopamine deficiency. Since long-term use of dopaminergic drugs has been shown to make symptoms worse or onset earlier in the day, doctors will often prescribe the lowest dose possible. However, even at low doses, sometimes these drugs lose their efficacy.
• The antiseizure medicine gabapentin has been approved by the FDA to treat RLS. Studies show that it works by interacting with calcium channel proteins, resulting in fewer and less severe symptoms.
• Opioids are used judiciously when other first-line treatments are ineffective or make symptoms worse. Because of the risk of addiction, doctors will prescribe low doses and monitor usage carefully.

Understanding Restless Legs Syndrome

As many of us who have RLS know, you could have this condition for years before realizing that you can take steps to lessen discomfort. This is due in part to the fact that we don’t know how to identify symptoms or may not even realize that there are two different types of this condition: Primary Restless Legs Syndrome and Secondary Restless Legs Syndrome.

Click here for more information on the two types of RLS.

Common symptoms of RLS 

• An overwhelming urge to move your legs. This is the defining symptom of RLS. Many people who experience RLS find this urge difficult to describe, but according to the National Institute of Neurological Disorders and Stroke, it is often described as “aching, throbbing, pulling, itching, crawling, or creeping.”
• The urge gets worse during inactivity. Most people with RLS find that movement can temporarily relieve their discomfort, and when they stop moving (for instance, to go to bed), the urge gets worse. If you experience discomfort in your legs that is not relieved with movement or does not get worse with inactivity, then you are probably not experiencing RLS.
• Periodic limb movement disorder (PLMD). According to the Cleveland Clinic, 80% of people with RLS also experience PLMD. This is an additional disorder that causes involuntary twitching or jerking of the limbs while you are asleep.
• Insomnia. Because the restlessness tends to get worse at night, many people with RLS also have a lot of trouble sleeping. According to a large survey, insomnia is one potential predictor for RLS because many people who reported having RLS also reported insomnia.

Causes of Restless Legs Syndrome 

Restless Leg Syndrome affects 5-10% of adults and 2-4% of children, with women having the condition slightly more often than men.

Researchers still can’t say for sure what causes RLS, but they have discovered evidence linking it to a few different factors, including genetics, pregnancy, iron abnormalities, and kidney abnormalities. They have also linked RLS with other conditions such as ADHD, Parkinson’s disease, spinal cord, and neurological abnormalities, Rheumatoid Arthritis, and Sleep Apnea. 

To read more about the factors that contribute to restless legs syndrome and other conditions associated with it, click here. 

The Takeaway

Although restless legs syndrome is not a fun condition, it isn’t a hopeless one either. There are many treatment options out there to help reduce the uncomfortable, sometimes painful urge to move. There are several medications for RLS, but if you don’t love pills, there are lifestyle changes you can adopt and non-drug treatments you can try, like acupuncture. You don’t have to lie awake at night feeling miserable anymore, you have options; there are treatments. So talk to your doctor today to find the right solution for your restless leg syndrome.

Additional Information On RLS

Primary Restless Legs Syndrome

Primary RLS is also sometimes known as hereditary RLS, because it is passed down genetically, or idiopathic RLS, because there is no known cause. Essentially, if you have primary RLS, that means your restlessness is not caused by another condition, like pregnancy, iron deficiency or Attention-Deficit Hyperactivity Disorder (ADHD).

The uncomfortable urge to move your legs at night is your primary issue, and it is not caused by some other disorder.

Secondary Restless Legs Syndrome

Secondary RLS is diagnosed when a person experiences restless leg syndrome caused by another condition. There are many conditions that can lead to RLS as a symptom, and there are even some medications used for other disorders that could cause RLS.

Sometimes, it’s possible to get better or different treatment for your primary condition in order to relieve your secondary RLS. 

Causes Linked to Restless Legs Syndrome

Genetics

Although doctors can’t confirm that RLS is definitely genetic, they have found some evidence that genetics could play an important role.

According to the Mayo Clinic, there appears to be a genetic link in about half of people with RLS, and people with familial RLS (RLS passed down in families) are more likely to show symptoms earlier, likely before age 40.

Pregnancy

One common cause of secondary RLS is pregnancy. According to one study, RLS is two to three times more common in pregnant people than in the general population.

Unlike primary RLS, many people who experience RLS while pregnant typically stop exhibiting symptoms after delivery. It’s unclear why RLS is more common during pregnancy, but some researchers believe it could be linked to the next cause on our list: iron abnormalities.

Iron Abnormalities

According to John Hopkins Medical, “the single most consistent finding and the strongest environmental risk factor associated with RLS is iron insufficiency.”

Considerable research shows that iron deficiency is highly linked to RLS, but many people with sufficient iron in their blood still have RLS. That’s because many people with RLS actually have plenty of iron in their blood, but not enough iron in their brains.

Researchers are still unsure about how iron is distributed throughout the body and what could cause differences in iron levels in the blood compared to iron levels in the brain, but many believe this connection could lead to meaningful treatment for many people with RLS.

Kidney Abnormalities

If you have kidney issues, like chronic kidney disease or end-stage renal failure, then you are far more likely to also experience RLS. According to the Renal Association, people with kidney issues, especially those on hemodialysis, are far more likely to have low iron, high calcium, and anemia, all of which have been linked to RLS.

It seems that iron abnormalities are the primary cause of RLS among kidney disease patients, but the kidney disease makes iron abnormalities much more likely, thus making RLS more likely as well.

Conditions Associated with RLS 

ADHD 

RLS and ADHD have a complicated relationship. It’s not uncommon for people with RLS to be misdiagnosed with ADHD, and vice versa. In reality, the two often go together.

In 2005, some researchers reviewed the literature surrounding RLS and ADHD and found that 44% of subjects with ADHD also had RLS, and 26% of subjects with RLS also had ADHD. This same literature review says that the two conditions could be linked by a neurotransmitter called dopamine.

It is well-known that ADHD is associated with dopamine abnormalities, and according to the National Health Service in the UK, RLS is also associated with dopamine abnormalities. One other study also found that the connection between ADHD and RLS could also be a result of iron deficiency, though more research needs to be done to confirm anything.

Luckily, both of these possibilities have treatment options available. Dopaminergic medications can help regulate dopamine production, and iron supplements can help keep iron levels stable. Both of these treatment options can help reduce the severity of RLS symptoms.

Spinal Cord Abnormalities 

Several spinal cord abnormalities have been linked to RLS symptoms. Spinal cord ischemia, which is when blood flow to certain areas of the spinal cord is reduced, has been known to contribute to RLS symptoms.

In a case study of one 60-year-old man already previously diagnosed with RLS, researchers found that spinal cord ischaemia in the neck area caused a severe increase in RLS symptoms.

Researchers believe the ischaemia was caused by a spinal cord lesion, which makes sense because spinal cord lesions and injuries are also associated with RLS. According to one small study, 100% of patients with spinal cord injuries also had symptoms of RLS.

This staggering statistic, along with other studies, has led researchers to believe that RLS could be caused, in some cases at least, by nerve damage of the spine.

Unfortunately, spinal cord injuries cannot be healed completely, but recovery and rehabilitation is possible, and these treatments can help reduce the severity of RLS symptoms as well.

Neurological Abnormalities

Neurological abnormalities come in many different varieties, and many of them are associated with RLS symptoms. This makes sense since RLS itself is a neurological condition.

According to a 2019 literature review, studies have shown that RLS is associated with several other neurological conditions, including Friedreich ataxia and Tourette’s syndrome. Another study also found that RLS is associated with migraine.

Data from over 12,000 RLS patients was analyzed, and researchers found that 15% of RLS patients also suffered from migraine. In some cases, RLS symptoms might be relieved through the treatment of the other, comorbid neurological disorder, but many of these disorders have no definite treatment.

There are various medications to help with migraines and Tourette’s, but they can’t cure the neurological disorder completely. This means they likely cannot get rid of all of the symptoms of RLS either, but they can lessen them. Combined with other lifestyle changes, this may be enough to make your RLS very manageable.

Anxiety-Related Disorders

Like ADHD, anxiety disorders are another psychological condition associated with RLS. The same 2019 literature review found that 22% of RLS patients also have some kind of anxiety disorder.

These disorders range from generalized anxiety disorder to obsessive-compulsive disorder to panic disorder. However, it’s unclear how RLS and anxiety are related. Like the chicken and the egg, researchers aren’t sure whether RLS is caused by anxiety or the other way around.

Regardless of which came first, anti-anxiety medications can be a big help in reducing anxious symptoms and the RLS symptoms that come with it.

Parkinson’s Disease

Parkinson’s disease is another neurological disorder that seems to have a strong correlation with RLS. This makes sense because Parkinson’s is a dopamine-related neurological disorder, and research suggests RLS has a dopamine component as well.

However, RLS found in patients with Parkinson’s might not be the same as RLS in patients without Parkinson’s.

According to the American Parkinson’s Disease Association, some patients with Parkinson’s don’t have worsening RLS symptoms at night, which suggests it differs significantly from non-Parkinson’s related RLS. Still, dopaminergic medications can often help reduce RLS symptoms in patients with Parkinson’s, and general Parkinson’s treatment often helps reduce RLS symptoms.

Rheumatoid Arthritis

Rheumatoid arthritis (RA) is an autoimmune disorder where your body’s immune system attacks your connective tissue, causing joint pain and chronic inflammation. The pain associated with RA often disrupts sleep, but recent research has found that RLS could play a role as well.

One study found that 30% of RA patients also have RLS symptoms which they can easily distinguish from their RA symptoms. Researchers are still trying to figure out how the two might be related, but further research has shown that there is a higher rate of RLS among other connective tissue disorders like Sjogren’s syndrome, scleroderma, and lupus.

The typical treatments for RLS, like dopaminergic medications or iron supplementation, are safe for patients with RA, plus there are some lifestyle changes that could help as well.

Sleep Apnea and Sleep Deprivation

Restless leg syndrome has a serious negative effect on sleep, and sometimes those effects are compounded when it teams up with other sleep issues, like sleep apnea and sleep deprivation. Sleep apnea is a sleep disorder where breathing periodically starts and stops throughout the night. It lowers overall blood oxygen levels and typically leads to more daytime sleepiness.

According to the National Institute of Neurological Disorders and Stroke, worsening sleep apnea can trigger or worsen RLS symptoms. They report that increased sleep deprivation can have the same negative effect on RLS symptoms.

But according to a study about sleep apnea and RLS specifically, RLS symptoms don’t always go away when patients with both sleep apnea and RLS receive positive airway pressure therapy (the standard sleep apnea treatment). This study found that these patients who continued to show RLS symptoms were more likely to have more  severe RLS and other health issues like asthma and diabetes.

Chemotherapy

Many patients receiving chemotherapy report sleep disturbances and poor sleep quality, and it turns out this could be due in part to RLS. A small study looked at over 170 cancer patients undergoing chemotherapy and assessed their sleep quality and possible RLS symptoms. They found that 20% of patients qualified for an RLS diagnosis, and the RLS was not related to iron deficiency, one of the most common hidden causes of RLS.

Six months after the end of chemotherapy, only four people still exhibited RLS symptoms. This suggests that something about chemotherapy could be causing temporary RLS, but researchers aren’t sure what the exact cause is yet.

Still, treatment is possible. Lifestyle changes and dopaminergic medication seem to be an effective option for most chemotherapy patients.