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The mean age of onset is the third and fourth decade of life. Typically there is a slow progression over years but onset can be more rapid. There is a higher risk of RLS in those who have first degree relatives who also suffer from it. It has also been linked to iron deficiency anaemia and kidney disease. RLS is common in pregnancy. Medication is not recommended in pregnancy or when breastfeeding and management should follow the behavioural and physical advice below. Sensory symptoms can occur on their own but are often accompanied by periodic repetitive, involuntary leg movements, usually while asleep.
Diagnostic criteria for restless leg syndrome (2012 revised IRLSSG)
(all 5 criteria must be met)
Medication to reduce symptoms
Patients should be aware that medication is to reduce the symptoms but that complete eradication is unlikely. Medical treatment should be deferred as long as possible with behavioural measures tried first. Gabapentin and pregabalin can be used in patients with restless legs (advocated by NICE) but is off-label. The choice of drug is also dependent on side-effect profile risk.
Avoid using more than one agent at the same time for restless legs. If one fails titrate off and use another rather than adding on treatment.
Gabapentin or pregabalin (off-label indication)
Dopamine agonists - ropinirole, pramipexole and rotigotine skin patches
Patients must be made aware that dopamine agonists can cause an impulse control disorder. This means that while taking the drug they are at risk of spending more time/money on things which give them pleasure but which can be harmful, eg gambling, alcohol and drug addiction, excessive shopping, hypersexuality. Avoid dopamine agonists in those with a history of impulse control issues, eg alcohol misuse, substance misuse, gambling.
Impulse control disorders can emerge over time and patients on these medications for a long time should be asked about any emerging problems.
Repeat warnings on impulse control disorders at the time of any dose increases.
There is a risk of augmentation over time, ie that higher doses are needed to improve symptoms. Long-acting dopamine agonists increase the time to augmentation and should be used in preference to short-acting dopamine agonists. Rotigotine patches may be useful if patient also has daytime symptoms, please note that they can cause application site reactions. Do not exceed the dose stated by the BNF for RLS as this will not improve symptoms and demonstrates augmentation. Do not use in pregnancy.
Weak opiates (codeines) may be useful in patients with severe augmentation.
How can a neurology appointment help?
Last reviewed: 20 January 2020
Next review: 30 January 2023
Author(s): Consultant Neurologist
Approved By: TAM Subgroup of ADTC
Reviewer Name(s): Consultant Neurologist
Document Id: TAM284