Understanding Sleepwalking, Sleep Terrors, and Nightmare Disorder
Sleep Medicine • Neurology • Primary Care
Restless Legs Syndrome (RLS): A Common Sleep Disorder
Restless Legs Syndrome, also called Willis‑Ekbom disease, causes an uncomfortable urge to move the legs, usually worse at rest and in the evening, and often disrupts sleep. RLS is under‑recognised but treatable — this guide provides clinicians with practical assessment and management steps.
Core diagnostic features
- An urge to move the legs, usually accompanied by uncomfortable sensations.
- Symptoms begin or worsen during periods of rest or inactivity.
- Symptoms are partially or totally relieved by movement.
- Symptoms are worse in the evening or at night than during the day.
These criteria (International Restless Legs Syndrome Study Group) should be present and not better explained by another disorder.
Epidemiology & impact
- Prevalence estimates vary (5–10% in adults), higher in older adults and in those with comorbid conditions (renal failure, pregnancy).
- RLS can cause significant sleep disturbance, daytime sleepiness, mood symptoms and reduced quality of life.
Causes & associations
- Primary (idiopathic): often familial; dopaminergic dysfunction suspected.
- Secondary causes: iron deficiency (low ferritin), chronic kidney disease, pregnancy, diabetes, peripheral neuropathy, rheumatoid arthritis and certain medications (antidepressants, antipsychotics, dopamine antagonists, antihistamines).
- Strong genetic contribution in many cases — ask about family history.
Assessment checklist
- Confirm core diagnostic criteria and characterise severity, timing and impact on sleep/function (use the IRLS severity scale if available).
- Review medications and substances (SSRIs, SNRIs, antipsychotics, antihistamines, lithium, caffeine, alcohol) that can worsen RLS.
- Screen for secondary causes: check ferritin (target often >75 µg/L in symptomatic patients), renal function, diabetes, and signs of peripheral neuropathy.
- Sleep history: assess for periodic limb movements of sleep (PLMS) and comorbid sleep disorders (OSA). Consider overnight PSG if PLMS with clinical significance or other sleep pathology suspected.
- Assess for comorbid mood/anxiety disorders and daytime sleepiness; consider referral for neurology/sleep medicine when complex.
Differential diagnosis
- Leg cramps, peripheral neuropathy, positional discomfort, akathisia, nocturnal leg cramps, nocturnal leg pains (e.g., vascular claudication) and psychogenic sensations.
- Differentiate from akathisia — akathisia often involves inner restlessness affecting whole body and is commonly medication‑induced.
Treatment — general principles
- Treat identifiable secondary causes first (iron repletion for low ferritin, manage CKD, optimise glycaemic control).
- Start with non‑pharmacologic and conservative measures for mild symptoms: leg massage, moderate exercise, good sleep hygiene, avoidance of caffeine/alcohol and review of offending medications.
- Pharmacotherapy indicated for moderate‑to‑severe or sleep‑disrupting RLS — choose agent based on patient profile and risk of augmentation.
Pharmacologic options
| Drug class | Examples | Notes |
|---|---|---|
| Dopamine agonists | Pramipexole, Ropinirole, Rotigotine (patch) | Effective for symptom control but risk of augmentation (worsening symptoms over time) and impulse control disorders; use lowest effective dose and monitor. |
| Alpha‑2‑delta ligands | Gabapentin enacarbil, Pregabalin, Gabapentin | Good efficacy, preferred in patients at risk of augmentation or with comorbid pain; monitor somnolence and dizziness. |
| Iron therapy | Oral or IV iron (if ferritin low) | Replete iron when ferritin <75 µg/L (or <50 µg/L depending on guideline); IV iron for intolerance or insufficient response to oral therapy. |
| Opioids | Low‑dose oxycodone/naloxone combinations or tramadol | Reserved for refractory cases due to dependence risk and side effects; specialist oversight recommended. |
| Benzodiazepines / Z‑drugs | Clonazepam, Zolpidem | May improve sleep but limited effect on RLS symptoms; risk of dependence and daytime sedation — use cautiously. |
Special considerations: augmentation
Augmentation is a worsening of RLS symptoms (earlier onset, increased severity, spread to arms) that can occur with long‑term use of dopaminergic agents. Recognise early — management may include dose reduction, switching to an alpha‑2‑delta ligand, or iron repletion.
When to refer
- Refractory RLS despite first‑line treatments, suspected augmentation, complex comorbidity (severe CKD, neuromuscular disease) or uncertainty in diagnosis — refer to sleep medicine or neurology.
- Consider specialist review before starting opioids or for consideration of iron infusion.
Case vignette
Patient: A., 62, reports evening leg discomfort and irresistible urge to move legs for 6 months, worse when resting and relieved by walking. Ferritin 22 µg/L. Management: start oral iron and recheck ferritin after 8–12 weeks, advise sleep hygiene and moderate exercise; if symptoms persist consider gabapentin trial. Education about augmentation and follow‑up arranged.
தமிழில் — சுருக்கம்
RLS என்பது இரவில் கால் சோர்வும் அசௌகரிய உணர்ச்சியும் ஏற்படுவதால் தூக்கத்தைப் பாதிக்கக்கூடிய ஒரு பொதுவான நிலை. இரும்பு குறைபாடு, சில மருந்துகள், மற்றும் சில மருத்துவ நிலையில் இந்த சின்னங்கள் அதிகமாகின்றன; சிறந்த சிகிச்சை கிடைக்கும்.
Key takeaways
- RLS is diagnosed clinically by the urge to move legs with rest, relief with movement and evening worsening — always exclude secondary causes.
- Check ferritin and treat iron deficiency; conservative measures help mild cases; use alpha‑2‑delta ligands or dopamine agonists for moderate‑severe disease while monitoring for augmentation.
- Refer refractory or complex cases to sleep medicine/neurology; patient education and regular follow‑up are essential.