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Let me introduce myself. My name is Mark Sisson. I’m 63 years young. I live and work in Malibu, California. In a past life I was a professional marathoner and triathlete. Now my life goal is to help 100 million people get healthy. I started this blog in 2006 to empower people to take full responsibility for their own health and enjoyment of life by investigating, discussing, and critically rethinking everything we’ve assumed to be true about health and wellness...

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February 22 2018

Restless Legs Syndrome: Causes, Factors and Treatments

By Mark Sisson
31 Comments

Weibliche Füße mit Schlafanzug im Bett am Morgen in blauer BettwäscheFor anyone who’s experienced it, the frustration can be miserable. The countless tossing and turning, the minutes that tick by (turning into hours), and you STILL haven’t gotten a modicum of decent sleep. No matter how hard you try to ignore it, that urge to constantly move or stretch your legs just won’t let up.

Restless legs syndrome (RLS), aka Willis-Ekbom disease, affects a decent chunk of the population: thought estimates vary wildly, this 2017 representative survey places its prevalence between 5.7 and 12.3% of the population. That’s up to around 40 million people in the U.S. alone who go to bed every night knowing they’ll likely be kept awake for hours with that unrelenting, restless sensation.

Conventional RLS Treatments

For people suffering from moderate to severe RLS, pharmaceuticals like dopamine agonists, Alpha-2-delta ligands, opioids, anticonvulsants, and benzodiazepines are often prescribed.

Dopamine agonists operate under the assumption that RLS is linked to impaired dopamine function in the brain. While they do tend to produce good results in the short term, even at low doses they’re also notorious for augmentation, a scenario in which RLS symptoms actually worsen from taking the drug. They’re also commonly associated with an increased risk of impulse control disorders, like pathologic gambling, compulsive eating, and compulsive shopping. Not ideal.

Other common first-line treatments include alpha-2-delta calcium channel ligands, and in some cases, opioids. Alpha-2-delta ligands are often effective in treating RLS that occurs in tandem with painful peripheral neuropathy, certain forms of chronic pain, and even Parkinson’s disease; however, they’re also linked to depression and suicidal tendencies. Also not ideal. And then there are opioids. Whether they’re a viable treatment for RLS or not, they may undoubtedly introduce more problematic side effects and addictions than they’re worth for many people.

Nutritional and Medical Factors Related to RLS 

Magnesium

Magnesium, which most of us are seriously lacking, interacts with calcium in the body to help regulate the nerves and muscles. When serum magnesium levels are low, nerve cells become overactive and can get a bit trigger happy in sending messages to our muscles. The result is constant muscle contraction, which explains many of the symptoms of restless legs syndrome.

In a small study involving patients with mild to moderate RLS, oral magnesium every evening for 4 to 6 weeks improved symptoms in all patients. Another study involving a pregnant woman given intravenous magnesium sulfate for 2 days indicated complete recovery from RLS symptoms. Magnesium is considered “investigational”  by a larger review study, but research is scant. 

Despite the apparent lack of research on the link between RLS and magnesium deficiency or supplementation, there’s still a decent amount of positive anecdotal evidence. If you’re magnesium deficient, it’s worthwhile trying a magnesium supplement given it’s support for other elements of health. Some people chose chelated forms like magnesium glycinate, but others swear by transdermal magnesium and magnesium citrate.

Iron

Unlike magnesium, the link between iron deficiency and RLS has received plenty of attention in the literature. This 2007 study showed that RLS sufferers with low serum ferritin were more likely to experience an iron deficiency in the central nervous system. This, in turn, impedes dopamine signaling, the result of which is greater risk of RLS. A 2013 study verified these findings by using MRI to show that RLS sufferers have significantly lower iron content within several areas of the brain.

Considering the importance of iron for healthy dopamine signaling, the results make sense. And several studies have shown that RLS patients with low serum ferritin (generally less than 75 mcg/L) have responded well to both oral and intravenous iron.

Of the two dosages, oral iron supplementation is by far the safest and easiest, especially when combined with vitamin C. That being said, it’s important to get your ferritin levels checked at least every 3 to 4 months during oral iron supplementation to ensure you don’t go overboard, since excess iron imposes health risks. 

Vitamin D

Like iron, vitamin D appears to play a key role in dopamine synthesis and metabolism, meaning those who are deficient are more likely to experience RLS symptoms. A 2014 study showed that presence of RLS was significantly higher in vitamin D-deficient patients, while a 2015 study found that certain variations in the vitamin D3 receptor gene were associated with an increased risk of RLS.

Luckily, vitamin D treatment is a fairly straightforward affair, and it seems to yield good results for those dealing with RLS. One recent study showed that vitamin D3 treatment (oral or intravenous) in those who were deficient was able to improve symptoms from a median RLS severity score of 26 down to 10. While this impressive result hasn’t necessarily been reflected across the board, it suggests that vitamin D supplementation is worth a shot if you suffer from RLS. For most people (particularly in winter), it’s worth upping your vitamin D levels whether you’ve got RLS or not.

Alcohol

There isn’t a lot of research to support the association between alcohol and RLS, but plenty of anecdotal evidence suggests it’s worth exploring. Alcohol can otherwise lower sleep quality and increase conditions of sleep apnea, which in turn can contribute to worsening of RLS symptoms. In a European study spanning close to 19,000 people, those who drank at least 3 alcoholic beverages a day were more likely to have RLS. Even if that tops your usual imbibing, alcohol probably isn’t helping your restless legs.

SIBO and Other Gut Disorders

Whether you’re low in iron or not, it’s worthwhile considering the link between gut conditions like small intestinal bacterial overgrowth (SIBO) and restless legs syndrome. A 2011 study of 32 RLS subjects found that 69% of RLS sufferers had SIBO, compared to only 28% of healthy controls. As part of the same study, another 28% of RLS subjects had irritable bowel syndrome (IBS) compared with just 4% of controls. A Japanese study of 80 outpatients diagnosed with inflammatory bowel disease (IBD) found that 20% of them also suffered from RLS. In another study involving 272 Crohn’s disease outpatients, RLS prevalence was 30%, and 43% had suffered from RLS at some point in the past. Celiac disease has much the same relationship with RLS, with 1 in 4 celiacs also reporting RLS symptoms.

Conventional treatments for IBS patients have shown dramatic improvements in RLS symptoms, but this generally involves a heady dose of antibiotics. A more Primal-friendly course of action would involve regular use of a good quality probiotic and a low-FODMAP diet until your RLS symptoms improve. Here’s what I use.

Autoimmune and Inflammatory Diseases

It might seem like highlighting the association between RLS and both autoimmune and inflammatory disease states is something of a catch-all, but the fact remains that people with conditions like Parkinson’s disease, Alzheimer’s disease, Celiac disease, MS and rheumatoid arthritis are far more likely to suffer from RLS than healthy individuals. A literature review found that out of 47 RLS-associated conditions, 42 of them had an autoimmune or auto-inflammatory component. Another study published last year also found strong links between patients’ neutrophil-to-lymphocyte ratio, a key marker of systemic inflammation, and RLS.

As far as specific treatments go, this is where things get tricky and individualized. How you approach the problem depends on your inflammatory or immune condition, but improvements can almost always be achieved by adopting an anti-inflammatory, Primal type of diet. You know, one loaded with nutrient-dense, whole foods and relatively devoid of inflammatory foods. Adjusting lifestyle factors to reduce stress and increase movement and sleep will also make a huge difference, but more on that next.

Other Factors For Treating RLS

Stress

As far as nonpharmaceutical measures go, one of the most successful RLS treatments is simply to reduce stress. That means, of course, eliminating causes of stress in your life where possible, but healthy practices that ameliorate its impact are a good idea, too.

For example, in a 2012 study, 13 women with moderate to severe RLS were placed on an 8-week self-guided Iyengar yoga program. At the end of the 8 weeks, “participants demonstrated striking reductions in RLS symptoms and symptom severity, with symptoms decreasing to minimal/mild in all but 1 woman and no participant scoring in the severe range by week 8.” Another study published last year combined yoga with aerobic exercise for 12 weeks to see significant improvements in RLS symptoms—to the point where patients were able to reduce their dosages of the RLS drugs they were on.

If yoga isn’t your thing, there’s plenty of other stress-alleviating options. Getting out into nature, using guided meditation, trying an adaptogen supplement (with your doctor’s okay), and even watching a good comedy can all chip away at the stress we feel. 

Medications

Certain medications have been shown to contribute to higher risk and severity with restless legs syndrome. A literature review of applicable studies found that antidepressants, neuroleptic agents, dopamine-blocking antiemetics, and sedating antihistamines have a strong correlation to incidence and greater severity of RLS, and where possible should be avoided. Obviously, this isn’t always an option, but it’s worth exploring whether a substitution can be made. As always, discuss your concerns with your doctor before discontinuing any medication. 

Exercise

A 12 week trial involving 28 participants showed that aerobic and lower body resistance training produced significant improvements in RLS symptoms across the board. A smaller study found similar results, with aerobic exercise over the course of 16 weeks producing an average reduction in RLS severity of 42%.

Stretching has also been shown to improve RLS symptoms, so consider doing some light leg stretches before bed or when the restless legs hit.

Compression Devices

While a trifle inconvenient and decidedly uncomfortable, compression devices show some serious promise in treating RLS. A 2009 study had 35 subjects wearing either a therapeutic compression device or sham device for at least an hour a day for 1 month. After 1 month, the compression group saw significant reductions in RLS symptoms, with an almost 50% reduction in severity. Another study involving 10 RLS patients saw 1 patient pull out of the protocol due to discomfort, but the remaining 9 used a compression device for 1 to 3 months and saw either complete remission of RLS or a marked improvement in symptoms. Obviously, if the need is great, compression devices are worth considering.

Beyond traditional compression accessories, however, more comfortable measures like weighted blankets may offer relief for some people. Those without RLS may find they sleep better with them, too.

Pregnancy

An estimated 1 in 5 women experience RLS during pregnancy. And although RLS symptoms usually recede shortly after delivery, it can make sleep more difficult during pregnancy and even pose its own health risks.

Generally speaking, many of the non-pharmacological treatments outlined above are effective in reducing the symptoms of pregnancy-related RLS. It’s always a good idea to get regular blood tests, as low iron levels (a common contributor to RLS) are a common occurrence in pregnant women. Other risk factors for RLS during pregnancy include vitamin D deficiency, impaired calcium metabolism, and a lack of low-impact exercise. Address these factors, and you’re bound to see a difference.

Thanks for reading, folks. For those of you with RLS, what’s worked (and hasn’t worked) for you? Share your thoughts below. 

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31 thoughts on “Restless Legs Syndrome: Causes, Factors and Treatments”

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  1. I am an infrequent sufferer so great to see this article. Thanks Mark. I’ve found that lack of exercise and alcohol usually set me off. That said, when I spent five days walking Hadrian’s wall, averaging eighteen miles a day, fuelled only by a pack of jerky, a good evening meal and three pints of ale, I would get it every night despite being knackered!
    My only solution normally is a 3am set of the lesser known primal exercise: The Pyjama Squat.
    Does the job though tricky to explain when the daughters boyfriend catches you.

    1. I also get it either when I do or don’t exercise. In other words, if I hit a happy medium it seems to go off, but with too little or too much exercise… argh. My remedy is taking a tennis ball to bed to try to loosen up the muscles!

  2. Magnesium, magnesium, magnesium!!!! I dealt with this on and off for years and it was terrible. Looking back I am sure it was stress related. My go to for magnesium is Natural Calm (sometimes I buy the Vitamin Shoppe brand too) but probably any source would do. I have been taking it nightly for years now (probably close to ten) and restless legs are totally a thing of the past. I also think the magnesium just helps me sleep better in general. Maybe it’s in my head, but sometimes I think I feel my muscles relaxing as I sit in bed and drink it. Warning to anyone who tries it…start with a much lower dose then recommended and slowly work your way up so your digestive system can get used to it. Also, while the magnesium made an immediate difference, if you think your restless legs are stress related look for other ways to alleviate the stress.

    1. I, too, had problems before supplementing with magnesium glycinate. I also used to get some really bad muscle spasms throughout my back and neck, and it wouldn’t take much to stress me out. A naturopath told me to take magnesium after an MD told me my mag. level was fine. Sure enough, it did the trick. It’s one of the few supplements I take because I know that either my body doesn’t process it well enough or I don’t get enough from food. I do eat legumes periodically since they are high in natural mag.

  3. Thanks for this article. I too get RLS. Interestingly, unaccustomed exercise seems to increase it, if I am already having RLS regularly. I also notice it when I am in need of sleep. Fortunately, it is not severe enough to prevent the very thing whose lack is triggering it. Also, I see an increase in times of stress.

  4. I get this. Keto seems to help, but that might be because I really up my magnesium intake on keto. B vitamins make a difference for m as well.

  5. I’ve tried all of these with zero results. Nothing has every systematically eliminated nor reduced the occurrence of RLS for me.

    1. I use clonazepam , it the only thing that has ever helped. I have suffered with RLS over 50 years.

  6. For me the culprit is iron. I am prone to low iron levels, and have had a lot of trouble with restless legs in the past. I’d actually noticed the correlation myself between times I was eating mostly vegetarian, dreadfully low ferritin levels, and increasingly terrible RLS symptoms even before I read that low iron is associated with RLS. Now I know if I start to develop symptoms I need to get back on my iron supplements. I eat a lot more red meat and leafy greens now days, but when I was an “almost” vegetarian at times in the past, I would slowly get to a point of almost unbearable RLS. Couldn’t even sit in a chair in the evenings, much less get to sleep. Wish I’d made the link to iron sooner and saved myself a whole lot of misery, but life and health continues to be a journey of discovery. Note: not trying to bash vegetarianism, I had ethical vegetarian leanings myself, but I found it was terrible for my health. If I have to supplement heavily to get enough protein and nutrients, then I figure that can’t be the right diet for me. Grain free, lower carb paleo foods seem to work best for my body.

    1. “I had ethical vegetarian leanings myself, but I found it was terrible for my health.”

      Same story here. I didn’t like the idea of killing animals for food. Still don’t, but my body seems to need plenty of animal protein for optimal health. I eat a lot of red meat and in fact will start craving it if I don’t get enough (as was the case during the brief time I was a vegetarian).

  7. My husband was a regular sufferer and had the hardest time going to sleep because of it. Going 80% primal solved it for him. Now he only has trouble when he eats too much sugar (dinner at his dad’s place will do it nearly every time!).

  8. I use Tramadol or Ibuprofen and Ambien. Nightly. I also take Magnesium, I wish there was a magic bullet for RLS, Ibuprofen actually works fairly well or Naprosyn, but my GP actually would rather me take a half a Tramadol, he thinks it’s safer.

    1. Watch out for the ibuprofen. Chronic use can a lot of health issues. It can also cause loss of hearing, although you don’t hear much about that one (no pun intended). None of that stuff is really “safe” for long-term usage. It’s just that some are marginally less toxic than others. You might consider consulting with a naturopathic or functional medicine doctor. They are more likely to help you find the underlying cause as opposed to medicating the symptoms for the rest of your life.

    2. Tramadol works wonders! I had this so bad after foot surgery when I was sedentary for days. After my initial heavy pain meds, my doctor put me on Tramadol and magically the RLS disappeared. I looked it up and saw that sure enough, it was sometimes prescribed for that purpose. I don’t know about long term use though?

  9. Organic Blackstrap Molasses has helped me on many occasions.
    This tip was from my Holistic Nutritionist years ago. Has helped my restless legs, migraines and regularity in the past. Either straight up or mixed in hot water as a coffee alternative. The organic blackstrap molasses I have in front of me has a nice amount of Potassium, calcium, Iron, Vitamin B, & Magnesium in it per Tbsp.
    (Truth be told has a bit of sugar!). :/

  10. I have had RLS for several years but worse the last two years. I take magnesium, both orally and a topical spray on, iron, and cardidopa levodopa every day. I take the cardidopa only at night because it has a sleep ingredient in it. I avoid alcohol and sugar after about 2:00 pm, or it will take forever for my meds to work where I can sleep. The latest thing I have found that has made a huge difference is Plexus Nerve. I take it at night with my meds and can lay down and sleep pretty much all night. I started taking two a day–one morning and one night–and could sit at a movie during the day and sit during the evening and watch tv when I first started it. It is all natural. I would highly recommend you look into it if nothing else is helping. Sadly, with RLS, what works for one does not always work for another.

  11. Both alcohol and stress seem to be contributors for me. I use a topical magnesium lotion or oil and it works every time.

  12. 68 years old, have had rls for the past 30 years. I seem to be doing all the right things; Retired, no stress. 10 yr Crossfit ( 3 times CF Games Competitor) past 9 years of Farily Strict Paleo. Don’t drink. I have tried the magnesium, iron sleeping supplements. The only thing that seems to help is smoking marijuana right before bed. It relaxes me and allows me to fall asleep faster than normal

  13. Magnesium! I’ve been experimenting for the past couple months with transdermal magnesium in the form of Magnesium Chloride flakes — full body baths, foot baths, hand dipping in the jar of solution. Foot baths for husband. Cloth soaked in the solution and rubbed on our puppies’ bellies and underarms. Everyone in the house responds so well to this way of magnesium supplementation. Husband’s restless leg syndrome is gone and his sleep is calmer and more restful, snoring almost gone. Puppies sleep well through the night. My muscle cramps are gone. Curiously, my love of chocolate is also gone. Maybe it is true after all — what they say about magnesium deficiency and cravings for chocolate. It was very sudden and surprising — one day I just stopped liking or wanting it all of a sudden and has been like this for almost two weeks.

    1. I have had RLS since 2000 when I delivered our twins. My Mother had it too in her 40’s–50’s. I would say my RLS is chronic and very sever . I have to get up and stand at movie theaters and pull over ( sometimes) when driving. I have been on Ropinirole 4 mg for 18 yrs. I worry about that kind of long term perscription on my body.. I have to say Quinine works sometimes for me. Good advice about Vitamine D and Magnesium.

  14. Great article! Currently I’m on the paleo autoimmune protocol (AIP) and I supplement with magnesium citrate and vitamin D3, among others. My legs are much more at ease now. However, when I do get restless legs, I need a fix at the moment and I found that a short bout of TRE tension release exercise helps immensely. It was taught to me by a natural movement teacher and I didn’t think much of it at the time. But it helps, especially to calm the legs at night.

  15. Good to see an article on this. I used to get this, not so much anymore. Its been so long I’m not sure when was the last time. It began way before the talk I hear now and I called it “crazy legs.” You’d have found me in the middle of the night doing high impact stomps and jumps out on the deck or down in the yard in the middle of the night. I never tracked why it went away, but it was way more frequent before I was gluten freed, organic’d, vitamin D;d & magnesium’d.

  16. Oh how I wish I had read this about 8 years ago! My mother-in-law, who is no longer with us, sufferred terribly from RLS. I’m continually amazed by what we can do with diet and other natural remedies. Do you know if RLS tends to be hereditary? Would be good to know for my husband and children.

  17. I deal with this occasionally, and for whatever reason if I get up and drink about a half cup of orange juice it goes away within minutes. I always thought it was the potassium, but perhaps it is the vitamin C or the fact that my OJ is fortified with vitamin D? I don’t know, I’m just glad it works! Thank you for addressing this rarely discussed condition!

  18. I’ve had MS for 20 years and RLS for the past 10 years. As of just recently I have switched to a Paleo diet. But prior to that, I actually DISCOVERED a “CURE” for me with regards to RLS. I purchased Ashley Black’s Fascia Blaster to get rid of cellulite, but instead, I used it one evening on my legs when my RLS was flaring up. After 5 min of rubbing my leg with the device, I was able to go to bed and had no more RLS symptoms! Even better, after a few times of using the device, my RLS went from almost daily to about once a month! When it does happen, I whip out my Fascia Blaster and 5 min later I am RLS free and resting peacefully!! It did cause bruising the first few times, but after that no pain and no bruising. I am so grateful that I stumbled upon this “cure” for RLS. I’m not discounting other treatments, but for me this has completely removed my RLS problem! (Now if only it cured MS.)

  19. Mark … been reading you for so long…you used to make fun of this stuff.
    It seems now that you have changed your thinking a bit. You used to make it clear that WE are not all messed and broken up and it doesn’t take “doctors” to fix us…only help us along..like nature you used to say. Whats changed this thinking??
    Still think you da bomb dot com after all these years….:-)

  20. Not gonna use my real name, but when I get (usually, but not always, mild) RLS; I pull out my vibrator, ‘make myself happy’ — and I can go right to sleep through the night with no twitching or annoyance.

    I do use mag. oil; not reliably enough to say it works for this — but if anyone has an idea for a HEALTHY (preferably natural) preservative to put IN the mag ‘oil’ that I make from flakes (using distilled water), I’d appreciate it. I make a quart, keep most in the fridge, keep a small jar in the bathroom for post-shower application; actually use a measuring spoon to dole it out onto a paper towel for the wipedown — trying to keep the mag oil ‘clean’ by not dipping a papertowel into it — but, after a week or so, I still get …. something … growing in the jar… (silver/clearish, and/or black). I don’t want to stop making and using it; I don’t want to use icy-cold mag oil from the fridge, I don’t want to put a commercial preservative in it to be carried through the skin by it. Anyone know of something?