Restless legs syndrome: what to do when your legs won’t let you sleep at night

Authored by Dr. Sarika Arora, MD

Restless legs syndrome is a sleep/movement disorder that keeps you awake with an irresistible urge to move your legs. The condition affects up to 10% of Americans, but is more common in women. It tends to be most severe in people at mid-life or older, although it can occur at any age, even in young children.

If restless legs are causing your lack of sleep, here’s why it’s happening — and what you can do about it.

What is restless legs syndrome (RLS)?

Restless legs syndrome — also known as RLS or Willis-Ekbom disease — is a neurological condition related to the brain’s use of the neurotransmitter dopamine. Dopamine regulates sleep, mood, behavior, cognition and muscle movement.

Here are the five diagnostic criteria that help distinguish restless legs from many other conditions that produce similar effects:

1. You experience an unpleasant sensation of tingling, itching, or pins-and-needles in your legs — often described as “creepy crawly” or “electric” — accompanied by a strong urge to move. You can feel this in both legs, or sometimes just one.

2. The tingling sensation and urge to move your legs either starts or worsens when you’re at rest, whether sitting or lying down.

3. You feel almost immediate relief from the tingling sensation upon moving your legs or affected body parts — but the relief doesn’t last after you stop moving, and you may find yourself having to move every 30-60 seconds just to find relief.

4. Your symptoms are nearly always worst in the evening and at night, and they may interrupt or prevent your sleep. If you do get to sleep, it’s common to wake up feeling fatigued because you’ve been moving all night, even though you didn’t wake up — but you won’t necessarily feel sleepy during the day. (Lack of “profound daytime sleepiness” is a hallmark of RLS and a number of other “hyperarousal” syndromes.)

A first-degree relative with RLS is a significant risk factor, so there’s a strong genetic component. But other factors, including iron deficiency, pregnancy, kidney disease, ADHD and even frequent blood donation have also been linked to RLS.

Why can’t I sleep?

Restless legs syndrome happens due to the disruption in your circadian rhythm and dopamine signaling. This is why you experience it mostly at night. The circadian rhythms of daylight and darkness produce important responses in your brain. As it gets darker, the hormone norepinephrine triggers release of the “sleep hormone” melatonin to ready you for sleep. One of dopamine’s functions is to block norepinephrine so that melatonin levels fall. So it is a “wake-you-up” hormone that is usually released at daybreak.

Your circadian rhythm can be disrupted by a lot of factors — stress, poor nutrition, ill health or even staying up too late working or studying (especially if you’re looking at a screen!) — and that can throw off the proper timing of dopamine release, waking you up when you should be falling asleep.

For some people, RLS disrupts sleep intermittently — maybe twice a week or less. For others, it’s a chronic problem that interferes with your ability to function and affects your mood. Long-term sleeplessness has also been tied to chronic health problems, so it’s not a problem you should try to just “live with.”

What can I do?

Sleep drugs may seem like the obvious answer, but they aren’t always the best long-term solution for restless legs syndrome. While they may help you fall asleep, they don’t address the underlying neurotransmitter dysfunction that contributes to RLS symptoms. As a result, they often need to be taken night after night. Many can also leave you feeling groggy the next day, and some carry a risk of dependence or habit formation.

For these reasons, current guidelines encourage people with RLS — particularly if your symptoms are intermittent — to start with a set of nutritional and lifestyle approaches to try to improve your symptoms before considering medical therapies.

4 ways to improve your restless legs symptoms

1. Start with good sleep hygiene. One of the first steps in addressing any sleep disorder is to make sure you’re setting the stage for sleep even before you lie down. Going to bed at a regular time, turning off electronic devices at least 1 hour before you head for bed, reducing alcohol and caffeine intake, and creating a comfortable, quiet atmosphere in your bedroom are steps that may help anyone with insomnia or sleep disturbances, and RLS is no exception.

2. Exercise daily. Research shows that being sedentary is a significant risk factor for RLS. One study showed that 3 days of aerobic and resistance exercise per week was enough to significantly decrease RLS symptoms, possibly for two reasons: increased blood flow to the lower extremities and exercise-related endorphins that support dopamine release.

3. Get the nutrients your nerves need. Iron deficiency is one of the best-established nutritional contributors to restless legs syndrome (RLS), and evaluating iron status is one of the first steps many healthcare practitioners recommend. Rather than assuming your iron is low, ask your practitioner to measure your ferritin and other iron markers, since both deficiency and excess iron can cause problems.

Folate and vitamin B12 also play important roles in healthy nerve function and dopamine metabolism, while magnesium supports normal nerve signaling and muscle relaxation. Some studies suggest that correcting deficiencies in these nutrients may help reduce RLS symptoms in certain people.

Emerging research also points to the importance of Vitamins D, C and E. Low Vitamin D levels have been associated with more severe RLS symptoms in some studies, and restoring healthy levels may improve symptom severity in people who are deficient. Vitamin C enhances iron absorption and also acts as an antioxidant, while vitamin E helps protect nerve cells from oxidative stress. Together, these nutrients support healthy nerve and muscle function, circulation and iron utilization — all of which may contribute to healthier leg comfort. A high-quality multivitamin can provide these micronutrients in forms your body can actually absorb.

4. Try mind-body therapies. Some studies support the use of massage, acupuncture, music, and meditation for easing restless legs. It’s worth noting that one meta-analysis found that RLS responds particularly well to “the placebo effect” — almost 30% of RLS patients given placebo treatments experienced a positive improvement in symptoms. Our take on this finding is that it shows the power of the mind to achieve healing — so if there’s a mind-body therapy that you enjoy, chances are good that it can be used to quiet your restless legs.

However, keep in mind that whatever treatment you decide upon will work best when you take a comprehensive, holistic approach to health. Many of the non-drug approaches may help medication therapy work better, so don’t give up on them!