SymptomBrain & nerves
Restless Legs: Why Your Legs Can't Keep Still at Night
Restless legs is an uncomfortable urge to move your legs, usually with crawling, tingling, pulling or aching feelings deep in the calves, that starts when you sit or lie still, is worse in the evening and night, and eases when you walk or stretch. When this pattern is persistent, it is restless legs syndrome (RLS), also called Willis-Ekbom disease. Common triggers are low iron, pregnancy, kidney disease, some medicines and sleep loss. Iron replacement, habits and medicines bring relief for most people.
Also called: Restless leg syndrome, Willis-Ekbom disease, RLS, jittery legs, creepy-crawly legs
At a glance
- What it feels like
- Crawling, tingling, pulling, itching or aching deep in the legs with an irresistible urge to move them.
- Key pattern
- Starts at rest, worse in the evening or night, relieved by movement.
- Common triggers
- Low iron (ferritin), pregnancy, kidney failure, antihistamines, some antidepressants, caffeine and alcohol.
- Diagnosis
- Based on symptoms, plus blood tests for ferritin, iron and kidney function.
- Relief
- Iron if levels are low, walking and stretching, avoiding triggers, and prescription medicines for frequent symptoms.
When to get help
See a doctor within a day or two
- Restless legs with new leg weakness, numbness that is spreading, or loss of bladder control
- One leg that is swollen, red, warm and painful (possible blood clot)
Book a routine appointment
- Symptoms most nights that disturb your sleep or daytime functioning
- Symptoms that started or worsened after a new medicine
- Restless legs with tiredness, pale skin or heavy periods (possible low iron)
- Symptoms that started earlier in the day, spread to the arms, or became stronger while on treatment (possible augmentation)
Usually safe to manage at home
- Occasional mild symptoms after a long car ride, late caffeine, or a poor night's sleep
What restless legs feel like
People describe the sensations as:
- creepy-crawly, like insects under the skin
- fizzing, tingling or "electric"
- pulling, aching or throbbing deep in the calves
- an itch inside the bones
The sensations are in the legs (usually both), between the knee and ankle, but can also affect the thighs, feet and later the arms. The defining feature is the urge to move, and the relief that moving brings, at least while you keep moving.
Restless legs vs leg cramps
| Feature | Restless legs | Leg cramps |
|---|---|---|
| Sensation | Urge to move, crawling or tingling | Sudden, painful, hard muscle contraction |
| Muscle | Not tight | Visibly knotted |
| Relief | Moving or walking | Stretching the muscle |
| Duration | Persists while at rest | Seconds to minutes |
Positional discomfort, poor circulation, and nerve pain from neuropathy can also be confused with RLS.
Causes and triggers
Primary (inherited) RLS
About half of people with RLS have a family history, especially when symptoms start before age 40. It involves how the brain handles iron and dopamine.
Secondary causes
- Iron deficiency: low brain iron is central to RLS. Symptoms can occur even when ferritin is in the "normal" range but below about 75 ng/mL. See iron deficiency anemia.
- Pregnancy: affects around 1 in 5 pregnant women, especially in the third trimester. Usually resolves within weeks of delivery.
- Chronic kidney disease, especially on dialysis.
- Peripheral neuropathy from diabetes or other causes.
- Parkinson's disease, multiple sclerosis and spinal cord problems.
Medicines and substances that worsen symptoms
- sedating antihistamines (diphenhydramine, including in "PM" sleep aids) and many cold remedies
- anti-nausea medicines such as metoclopramide and prochlorperazine
- antipsychotics
- many antidepressants (SSRIs, SNRIs, mirtazapine). Bupropion is less likely to worsen RLS
- caffeine, alcohol and nicotine
- sleep deprivation
Related condition: periodic limb movements
Most people with RLS also have periodic limb movements in sleep: repetitive jerks of the legs every 20 to 40 seconds that bed partners notice. They fragment sleep and contribute to daytime tiredness.
How restless legs are diagnosed
There is no single test. A doctor confirms the four core features (urge to move, starts at rest, relieved by movement, worse in the evening) and rules out mimics. Blood tests should include ferritin and iron studies, a complete blood count, kidney function, and sometimes blood sugar, B12 and thyroid tests. A sleep study is occasionally needed.
How to relieve restless legs
Right now
- Get up and walk, or stretch your calves and hamstrings.
- Massage your legs, or try a warm bath, or alternate warm and cool packs.
- Do something mentally absorbing, such as a puzzle, while sitting.
- Use a pneumatic compression device or vibrating pad if you have one, which help some people.
Lifestyle
- Avoid caffeine, especially after midday, and limit alcohol and nicotine.
- Keep regular sleep times and avoid sleep deprivation.
- Exercise moderately during the day. Very intense exercise late in the day can worsen symptoms.
- Review your medicines with your doctor or pharmacist, especially antihistamines and antidepressants.
- Plan ahead for long trips: aisle seats and walking breaks.
Medical treatment
The 2024 American Academy of Sleep Medicine guideline recommends:
- Iron: oral iron or IV iron if ferritin is 75 ng/mL or below, or transferrin saturation below 20%. Take oral iron with vitamin C and away from food and tea.
- Alpha-2-delta ligands: gabapentin, gabapentin enacarbil or pregabalin, now first-choice medicines for persistent RLS.
- Dopamine agonists (pramipexole, ropinirole, rotigotine patch): no longer recommended for routine long-term use because of augmentation, where symptoms become stronger, start earlier and spread over time.
- Low-dose opioids for severe, refractory RLS under specialist care.
In pregnancy, iron if low, movement and good sleep habits are preferred. Discuss any medicine with your obstetrician.
Frequently asked questions
What causes restless legs at night?
RLS involves how the brain uses iron and dopamine, both of which follow a daily rhythm that dips in the evening. That is why symptoms are worse at night. Low iron, pregnancy, kidney disease, some medicines, caffeine and alcohol can trigger or worsen it.
What is the fastest way to stop restless legs?
Getting up and walking, stretching your calves, massaging your legs, or a warm bath usually bring quick, temporary relief. For lasting control, check and correct iron levels, avoid triggers such as antihistamines and caffeine, and talk to your doctor about medicines if symptoms are frequent.
What deficiency causes restless legs?
Iron deficiency is the most important. RLS can occur when ferritin is below about 75 ng/mL even without anemia. Some people also have low magnesium or vitamin D, but evidence that supplements help is limited compared with iron.
Why do I get restless legs in pregnancy?
Pregnancy changes in hormones, iron and folate levels, and increased iron demand all raise the risk, especially in the third trimester. Symptoms usually disappear within a few weeks after birth. Ask your provider to check your ferritin.
Is restless legs a sign of something serious?
Usually not. RLS is common and often runs in families. It can be linked with iron deficiency, kidney disease, neuropathy or Parkinson's disease, so a check-up with blood tests is worthwhile when symptoms are frequent.
Sources
This guide was written from current patient and clinical guidance, including:
- National Institute of Neurological Disorders and Stroke: Restless Legs Syndrome
- American Academy of Sleep Medicine: Clinical Practice Guideline for the Treatment of Restless Legs Syndrome (2024)
- Restless Legs Syndrome Foundation: RLS Basics
- NHS: Restless legs syndrome
- MedlinePlus: Restless legs syndrome