Does RLS get worse over time?

Primary RLS tends to be a progressive condition for many people, with symptoms gradually increasing in frequency and severity over years. However, the course is variable — some people have stable symptoms for years, and periods of improvement are possible. Secondary RLS caused by iron deficiency or pregnancy can resolve completely when the underlying cause is treated.

Is restless legs syndrome the same as leg cramps?

No. Leg cramps are painful muscle contractions that are often sudden in onset and typically relieved by stretching. RLS involves uncomfortable sensory symptoms (crawling, aching, pulling) with a strong urge to move, without the sharp muscle contraction of a cramp. They can both occur at night and be confused, but the treatment and cause differ significantly.

Can children get RLS?

Yes. RLS occurs in children and adolescents, though it is often unrecognised. In children, RLS may present differently — the sensations may be described as 'growing pains' or discomfort that the child cannot clearly articulate. RLS in children is associated with ADHD and with iron deficiency. Children with suspected RLS should see a paediatrician or sleep specialist.

What is augmentation in RLS and should I be worried?

Augmentation is a complication of dopamine agonist treatment (pramipexole, ropinirole) in which symptoms paradoxically worsen over time on the medication — starting earlier in the day, spreading to other parts of the body, and becoming more intense. It affects a significant proportion of long-term users and is a major reason why gabapentinoids are now often preferred as first-line treatment. If you notice your RLS symptoms worsening while on a dopamine agonist, speak to your doctor rather than increasing the dose.

Restless Legs Syndrome (RLS) | whataresleepdisorders.com

Restless legs syndrome (RLS) — also known as Willis-Ekbom disease — is a neurological sensorimotor disorder causing an uncomfortable, often irresistible urge to move the legs. The sensations occur predominantly at rest and worsen in the evening and at night, making it one of the most disruptive and underrecognised causes of chronic insomnia. RLS affects an estimated 5–10% of adults, yet it is frequently dismissed or misdiagnosed.

What Is Restless Legs Syndrome?

RLS is defined by four essential diagnostic criteria, all of which must be present:

An urge to move the legs, usually accompanied by uncomfortable or unpleasant sensations
The urge and sensations begin or worsen during periods of rest or inactivity (sitting or lying down)
The urge and sensations are partially or completely relieved by movement — walking, stretching, or jiggling the legs — at least temporarily
The urge and sensations are worse in the evening or night than during the day, or occur only in the evening or night

The sensations themselves are notoriously difficult to describe. People use words such as crawling, creeping, pulling, throbbing, aching, itching, burning, or an electric current running through the legs. They are typically felt deep inside the leg rather than on the skin surface, most commonly in the calf. In more severe cases, the arms and other parts of the body can be affected.

RLS ranges from mild (occasional, manageable symptoms) to severe (nightly, with major disruption to sleep and quality of life). Many people with moderate-to-severe RLS describe lying in bed at night as a form of torture — the need to keep moving prevents sleep, while stopping movement immediately brings the uncomfortable sensations back.

Types of RLS: Primary and Secondary

RLS is categorised into two forms based on whether an identifiable underlying cause exists:

Primary (idiopathic) RLS: No identifiable underlying cause. This form tends to run in families — if a first-degree relative has RLS, your risk is three to five times higher. Primary RLS tends to be a lifelong condition that may worsen gradually over time.

Secondary RLS: Caused by or associated with an underlying medical condition or deficiency. The most important secondary causes include:

Iron deficiency: Even in the absence of frank anaemia, low ferritin levels (below 75 micrograms per litre) are strongly associated with RLS and may directly cause or worsen it. Iron is required for the production of dopamine, and dopamine dysregulation in the brain is central to the pathophysiology of RLS.
Chronic kidney disease: End-stage renal disease carries a particularly high prevalence of secondary RLS, affecting up to 25–40% of patients on dialysis.
Pregnancy: RLS occurs in approximately 20–30% of pregnant women, most commonly in the third trimester, and usually resolves after delivery. Iron deficiency and hormonal changes during pregnancy are thought to be the primary drivers.
Peripheral neuropathy: Nerve damage from diabetes, alcohol, or other causes can trigger or worsen RLS.
Medications: Several commonly prescribed medications can cause or significantly worsen RLS, including antidepressants (particularly SSRIs and tricyclics), antipsychotics, antihistamines, anti-nausea drugs, and certain antihypertensives.

Periodic Limb Movement Disorder (PLMD)

Many people with RLS — approximately 80% — also have a related condition called Periodic Limb Movement Disorder (PLMD). This involves repetitive, involuntary jerking movements of the legs (and sometimes arms) during sleep, typically occurring every 20–40 seconds. Unlike RLS, PLMD occurs during sleep and the person is usually unaware of it — though a bed partner is frequently not. PLMD further fragments sleep and contributes to daytime fatigue in people with RLS.

How Is RLS Diagnosed?

RLS is primarily a clinical diagnosis based on the four diagnostic criteria described above. There is no blood test or brain scan that confirms RLS. A doctor will:

Take a detailed history of your symptoms, their timing, triggers, and relief factors
Review your current medications (several can cause or worsen RLS)
Order blood tests including a serum ferritin level — this is essential in every patient with RLS and is often the most important finding, as correcting iron deficiency can resolve or dramatically improve symptoms
Screen for associated conditions (kidney disease, diabetes, neuropathy)
Consider a sleep study (polysomnography) if PLMD is suspected or if another sleep disorder needs to be excluded

When to Speak With a Doctor

If you are regularly lying awake at night because of an irresistible urge to move your legs, or if uncomfortable leg sensations are preventing you from sitting through films, long journeys, or evening activities, speak to your GP. Ask specifically for a serum ferritin blood test — this is frequently the most important and treatable factor in RLS, and is often overlooked.

Treatment Options

Treatment depends on whether RLS is primary or secondary, its severity, and the impact on daily life and sleep. A stepwise approach is typical:

Address Underlying Causes First

If iron deficiency is identified (ferritin below 75 micrograms per litre), iron supplementation is the first step and can produce dramatic improvement. Oral iron combined with vitamin C to enhance absorption is standard, taken on an empty stomach. If oral iron is not tolerated or absorption is poor, intravenous iron infusion can provide faster and more reliable replenishment. Medications that worsen RLS should be reconsidered or substituted where possible.

Lifestyle and Non-Drug Measures

Regular moderate exercise (but not vigorous exercise close to bedtime, which can worsen symptoms)
Avoiding caffeine, alcohol, and nicotine, particularly in the evening
Leg massage, hot baths, or warm compresses before bed
Mental engagement activities to distract from symptoms (video games, puzzles)
A consistent sleep schedule and good sleep hygiene practices

Pharmacological Treatment

Alpha-2-delta ligands (gabapentinoids): Gabapentin and pregabalin are now often preferred as first-line medications for RLS, particularly where pain or sleep disruption are prominent. They reduce the uncomfortable sensations and improve sleep.
Dopamine agonists: Pramipexole, ropinirole, and the rotigotine patch were historically first-line treatments. They are effective but carry a significant risk of augmentation — a paradoxical worsening of RLS symptoms over time that affects up to 50% of long-term users. Their use requires careful monitoring.
Low-dose opioids: For severe, refractory RLS unresponsive to other treatments, low-dose opioids (such as oxycodone extended-release or methadone) may be considered under specialist supervision.

References

Allen RP, et al. Restless legs syndrome: diagnostic criteria, special considerations, and epidemiology. Sleep Medicine. 2003;4(2):101–119.
Garcia-Borreguero D, et al. Guidelines for the first-line treatment of restless legs syndrome/Willis-Ekbom disease. Sleep Medicine. 2016;21:1–11.
National Institute of Neurological Disorders and Stroke (NIH). Restless Legs Syndrome Fact Sheet.
Earley CJ, et al. The Johns Hopkins telephone diagnostic interview for the restless legs syndrome. Sleep Medicine. 2014;15(7):841–845.
Trenkwalder C, et al. Augmentation in restless legs syndrome is associated with low ferritin. Sleep Medicine. 2008;9(5):572–574.