KISS: Restless Legs Syndrome, Willis-Ekbom Disease

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Make the diagnosis

  • The 5 essential diagnostic criteria (patients must have all 5) are:
    • An urge to move the legs usually accompanied by unpleasant sensations in the legs
    • This usually occurs during periods of rest or inactivity
    • The urge to move and accompanying sensations are eased by movement
    • Symptoms are worse in the evening and night than during the day
    • The features are not explained by another condition e.g. leg oedema, arthritis etc
  • Assess severity with RLS international rating scale

Is it primary or secondary (associated conditions or drugs)?

  • In most it is idiopathic, 50% have a positive family history
  • The most common secondary causes are iron deficiency, renal disease and peripheral neuropathy
  • Commonly prescribed drugs can exacerbate it: antihistamines, anti-nausea drugs, dopamine antagonists, antidepressants including SSRIs, beta-blockers, some antiepileptics and lithium

Investigations: Check iron studies, especially ferritin, in all. Consider FBC, U&E, LFT, TSH, glucose, B12, calcium studies, inflammatory markers.



  • Review medication and stop/change exacerbating drugs
  • Treat with iron if ferritin <50mcg/ml and aim to keep ferritin > 50-75 long-term
    • new evidence suggests that iron may be beneficial even in patients with normal ferritin levels 
  • MILD RLS: advice and reassurance are generally sufficient
    • Good sleep hygiene, reduce caffeine and alcohol, stop smoking
    • Increase daytime exercise. Walking, stretching, relaxation exercises
  • MODERATE TO SEVERE RLS, consider drug treatment if significant impact on the quality of life
    • Dopamine agonists and gabapentinoids are both effective at helping the sensory symptoms
    • Start with gabapentin (600 to 1200mg daily) or pregabalin (150mg to 450mg daily)
    • Dopamine agonists are highly effective but long-term have a diminishing response and can cause augmentation of symptoms. Avoid unless absolutely necessary, and then use the lowest effective dose for the shortest possible time e.g. pramipexole or ropinirole
  • Referral to a neurologist?
    • Refer if doubt about the diagnosis, or symptoms refractory to treatment or if augmentation occurs with a dopamine agonist

NHS Patient information

Restless Legs Syndrome, UK support & information charity

Published on 13th February 2020

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