Synopsis
Diagnose restless legs syndrome from its urge–rest–relief–evening pattern, identify iron deficiency, kidney disease, pregnancy and medicine triggers, and prevent dopaminergic augmentation through proportionate first-line treatment and monitoring.
- The diagnostic core is an urge to move the legs, usually with unpleasant sensations, beginning or worsening during rest, relieved by movement and more prominent in the evening or night.
- Walking, stretching, rubbing or moving brings temporary relief; pain that persists unchanged during movement or occurs mainly on exertion suggests another cause.
- Primary RLS can be familial, but iron deficiency, pregnancy, chronic kidney disease and some neurological disorders are important associated states.
- Review medicines that may worsen symptoms, including dopamine-blocking antiemetics or antipsychotics, sedating antihistamines and some antidepressants, while never stopping essential treatment abruptly.
- Check full blood count, ferritin and transferrin saturation because iron depletion can exist without anaemia and ferritin may be misleadingly raised by inflammation.
- Nocturnal leg cramps cause a painful palpable contraction, neuropathy causes persistent burning or numbness, and akathisia creates whole-body inner restlessness without the characteristic evening sensory pattern.
- Start with explanation, regular sleep, moderate daytime activity, stretching or massage, and reduction of late caffeine, nicotine and alcohol where relevant.
- Replace demonstrable iron deficiency using a locally governed oral or intravenous plan, documenting the biochemical target and excluding unsafe iron loading.
- Gabapentin or pregabalin may be preferred for frequent troublesome disease, especially with pain or insomnia, but sedation, dependence potential and renal dosing require care.
- Dopamine agonists can cause augmentation—earlier, more intense, rapidly provoked and anatomically spreading symptoms—and impulse-control disorders, so they are not a consequence-free chronic solution.
Key red flags
Symptoms that start progressively earlier, appear after shorter rest, become more severe or spread from legs to arms during dopamine therapy suggest augmentation rather than simple disease progression.
Investigation priorities
Identify iron depletion, anaemia and a treatable contributor before symptomatic medication is escalated.
Management branches
Night-time leg discomfort, urge or insomnia is reported.
- 1. Ask whether symptoms begin at rest, are temporarily relieved by movement and show evening predominance, documenting exceptions and severity.
- 2. Compare cramps, neuropathy, venous disease, arthritis, positional discomfort and akathisia through sensory description, examination and medication timing.
- 3. Assess sleep loss, mood, work, pregnancy and kidney disease, and ask whether a relative has a similar pattern.
- 4. Request iron indices and relevant renal or metabolic tests before assigning primary disease or starting long-term symptomatic medication.
Key medicines
Oral iron replacementWhen biochemical deficiency is confirmed, a common regimen is ferrous sulfate 200 mg once daily or on alternate days, adjusted to elemental iron, tolerability and the local replacement protocol.Confirm deficiency and investigate its cause. Explain gastrointestinal effects and interaction spacing, recheck indices after a defined interval and avoid continued iron when stores are adequate or overload is possible.
PregabalinA specialist or experienced prescriber may start 25–75 mg in the evening and titrate cautiously to symptom response, reducing dose in renal impairment under current BNF guidance.It is a controlled drug with sedation, dizziness, oedema, weight gain, misuse and dependence potential. Avoid abrupt withdrawal, review respiratory depressants and discuss pregnancy and driving.