NORTHERN NIGHTS
SLEEP DISORDER CENTRE

Restless Limb Syndrome

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You can print the current version of the diagnosis and treatment quide I provide for family physicians.
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Please ensure that the recommendation are up to date. This page was last updated on 2009 Nov 29.

Making a diagnosis:

The diagnosis is made by obtaining a typical history: Sleep studies are not required to make a diagnosis of restless limbs syndrome. (Reference 1)

If the symptoms respond to dopamine agonist therapy it strongly supports the diagnosis.

If the symptoms do not respond, even transiently, then the diagnosis becomes less likely.

Basic workup:

  1. Obtain a clear history, looking for the points listed above.
  2. Examine the patient's legs looking for neuropathy, vascular disease, or other causes of the symptoms. Consider referral for nerve conduction studies if there is evidence of neuropathy.
  3. Ask about caffeine intake (and make sure the patient minimizes it)
  4. Screen for metabolic causes of restless limbs: check the patient's Ferritin; TSH; Hgb; WBC;Folate; B12; Ca Mg; Cr, Na K; glucose, Hgba1c. Correcting abnormalities may resolve the symptoms. Note that a ferritin in the lower third of the normal range should be treated with iron supplements, particularly in pregnant women, as well as considering investigation for potential causes.
  5. Consider a trial of therapy unless there are contraindications.
  6. Consider phoning for advice, rather than referring the patient, particularly if the patient's symptoms are severe.
  7. A diagnostic sleep study is usually not indicated unless there are atypical features, or poor response to therapy.

First line therapy:

  1. In my opinion, the selective dopamine agonist pramipexole is the current treatment of choice. (reference 2) (reference 3)

    The starting dose is 0.125 mg as a single dose in the evening. Response is usually immediate at this level or at 0.5 mg.

    Patients may experience nausea; postural dizziness; vivid dreaming. These generally occur at the beginning of therapy and are transient.

    Drowsiness in the daytime has been reported particularly in patients taking the medication at higher doses and with doses in the daytime.

    An infrequent but unusual side effect is compulsive behaviours, such as compulsive gambling. This is rare, and generally only seen at higher doses, but I caution every patient about the possibility.

    Avoid using split doses given earlier than ~1500-1600 hrs, and avoid progressively escalating doses for increasing symptoms, or symptoms that rebound during the night and in the morning.

  2. Ropinirole 0.25-0.5 mg is another selective dopamine agonist that is a reasonable choice. (reference 4)
    Levodopa/carbidopa is sometimes used on a PRN basis, for example for patients who have restless limbs in certain specific situations such as air travel, or in movie theaters. However, if they need regular dosing this is not a good therapy because of short half-life, and problems with rebound and augmentation effects.

  3. I do not use clonazepam or other benzodiazepines as first-line drugs. Benzodiazepines work by causing sedation, and do not reduce restlessness or movements, and are often associated with significant side effects.

  4. Familiarize yourself with product monographs before prescribing any drug for a patient.

  5. Do not prescribe anything for pregnant women with restless limb syndrome, except for iron supplements in pregnant women with low iron levels, or with ferritin levels below the lower third of the normal range.

When to refer:

  1. If the person doesn't respond to selective dopamine agonists.
  2. If you are uncertain about the diagnosis, and there is some reason you can't do a trial of dopamine agonists to clarfiy the diagnosis.
  3. If there is evidence of peripheral neuropathy and symptoms of RLS (refer to neurology).

    When you do refer the patient:

    1. Document your findings and treatment to date, including lab results. Make sure you have measured the ferritin, TSH, and Ca at a minimum (see above).
    2. If you are uncertain about the diagnosis, and there is some reason you can't do a trial of dopamine agonists to clarfiy the diagnosis.
    3. Consider phoning for advice first, especially if the patient's symptoms are severe.