Restless legs syndrome: symptoms and treatment

The urge to move at rest and in the evening

Restless legs syndrome, or RLS, causes an urge to move the legs, often accompanied by uncomfortable sensations. Symptoms typically begin or worsen during rest, become more troublesome in the evening or at night, and improve temporarily with movement. Walking may bring relief, only for the sensations to return when you sit or lie down again. ¹

People use different words for the feeling: crawling, pulling, aching, or an internal discomfort that is hard to describe. What helps distinguish the pattern is when it happens and how it responds to movement. RLS is also different from periodic limb movements during sleep, which involve involuntary movements. Many people with RLS have those movements, but movements alone do not establish RLS. ¹

Clinical assessment and iron testing

There is no single test that confirms RLS. A clinician considers symptoms, medical history, medicines, and an examination, while looking for other explanations. Conditions such as leg cramps, neuropathy, and positional discomfort can resemble parts of the complaint. Describe the urge to move, when it starts, and whether walking relieves it. ¹²

In its 2025 guideline, the AASM recommends checking iron studies, including ferritin and transferrin saturation, in people with clinically significant RLS. The iron thresholds used in RLS care differ from those used for the general population. That is a reason to ask how your results apply to this condition rather than interpreting a laboratory flag on its own. ²

The same guideline says to address factors that can worsen RLS, including caffeine, alcohol, untreated obstructive sleep apnea, and certain medicines. Some antihistamines, medicines affecting serotonin, and medicines blocking dopamine can contribute. Ask a pharmacist or prescriber to review the exact products you use, including occasional allergy and sleep remedies. ²

Iron supplements and follow-up tests

Iron is not an all-purpose remedy for uncomfortable legs. Supplements can cause adverse effects and interact with medicines; excessive amounts can be dangerous. If a clinician recommends iron, clarify the formulation, dose, timing, and follow-up tests. Follow the prescribed instructions rather than adding several iron-containing products together. ³

Bring a list of supplements and medicines to the discussion. This is especially useful if a multivitamin already contains iron or if you take medicines that may need to be separated from an iron dose. Store iron safely away from children. Ask when symptoms and iron results will be reviewed, and what would lead to a dose change or stopping treatment. ³

Why guidance on dopamine medicines changed

Some dopamine-related medicines can relieve RLS in the short term but lead to augmentation: treatment-related worsening that can bring symptoms earlier in the day or make them more extensive. The AASM now suggests against routine use of several dopamine agonists and levodopa, while recommending options such as gabapentin, gabapentin enacarbil, and pregabalin for appropriate adults. If you already take a dopamine-related RLS medicine, do not stop it abruptly. Severe rebound symptoms can occur; any change needs a plan with the prescriber, often involving a gradual reduction. ²

A 52-week randomized trial involving 719 participants helps illustrate the issue. Pregabalin improved symptoms compared with placebo. Augmentation was less frequent with pregabalin than with the higher pramipexole dose studied, but the difference against the lower dose was not statistically significant. ⁴

Treatment choice also depends on adverse effects and other health conditions. Ask what changes in symptom timing or severity to report during treatment. ⁴

Medication risks and changes to report

Gabapentin and pregabalin are not risk-free substitutes. The FDA warns about serious breathing problems in people with respiratory risk factors, including use of opioids or other central nervous system depressants; older adults also face greater risk. The prescriber needs to know about your full medication list and any lung or breathing condition. ⁵

For the next appointment, note which evenings symptoms occurred, whether resting brought them on, how movement affected them, and whether they have started earlier than before. Include any recent treatment changes. A warm bath, massage, or moderate regular activity may provide some relief, but recurring disruption still deserves assessment. Bring your notes to the visit together with the names and amounts of everything you currently take, including occasional sleep or allergy products. ⁶