Restless legs syndrome (RLS) causes a strong urge to move your legs while you rest, usually with a crawling, pulling or restless feeling deep in the calves. It comes mainly in the evening and at night, when you lie or sit, and eases as soon as you get up and walk. The exact cause is not fully understood. Genetics, iron metabolism and dopamine play a role, and some conditions and medicines can make it worse. About 3 to 10 percent of people in Europe have RLS, women about twice as often as men. According to the German guideline, the most important first step is to check your iron levels: at a ferritin of 75 µg/l or below, a doctor should give iron first, before other medicines are considered.
As of October 2026. Sources are linked below.
Key Takeaways
- What is RLS? A neurological movement disorder with an urge to move and unpleasant sensations in the legs, at rest, in the evening and at night.
- How common? 3 to 10 percent of people in Europe and North America; in about 1.3 percent of adults in Germany it is severe enough that treatment may be considered.
- Cause: not fully understood; genetics, iron metabolism and dopamine play a role. Some conditions and medicines can make RLS worse.
- Diagnosis: in conversation, using five criteria, plus blood tests for iron, kidney and thyroid.
- Treatment: treat triggers, iron if ferritin is low, further medicines for severe symptoms after medical assessment.
- What you can do: avoid coffee, nicotine and alcohol in the evening, massage or shower your legs, keep a calm sleeping environment.
What Is Restless Legs Syndrome?
RLS is a neurological, sensorimotor movement disorder. People describe an unpleasant feeling deep in the calves, such as restlessness, pulling, pressure or tension, and a strong urge to move the legs. Occasionally the thighs or arms are affected too. Because the symptoms start at rest and are strongest in the evening, they mainly disturb falling asleep.
Many people with RLS also move their legs involuntarily and repeatedly during sleep, known as periodic limb movements in sleep (PLMS). As a result they sleep less soundly and are often exhausted, irritable and have trouble concentrating during the day.
The Five Diagnostic Criteria
According to the guideline, the diagnosis is made in conversation when all five criteria are met:
- An urge to move the legs, usually with unpleasant sensations or restlessness in the legs.
- Starts or gets worse at rest, such as lying or sitting.
- Gets better with movement, such as walking or stretching, at least while the movement lasts.
- Occurs or is worse in the evening or at night.
- No other explanation, for example muscle pain, venous congestion, leg swelling, arthritis, leg cramps or an uncomfortable sitting position.
A questionnaire alone is not enough for the diagnosis. A sleep-lab study is not essential, but it is advisable when breathing pauses during sleep need to be ruled out.
What RLS Is Not: Similar Symptoms
Several conditions can feel similar. The guideline lists, among others:
| Condition | How to tell the difference |
|---|---|
| Peripheral artery disease (intermittent claudication) | pain when walking, better when standing still, no urge to move, not worse in the evening. More under peripheral artery disease |
| Varicose veins | symptoms after long standing, better when the legs are raised. More under varicose veins |
| Polyneuropathy | tingling, numbness or burning on the surface of the skin, often sock-shaped on the feet, also during the day, movement brings no lasting relief |
| Uncomfortable sitting position | pulling pain after sitting long in the same position, better with a simple change of position |
| Osteoarthritis | symptoms mainly in the joints, worse with strain, not worse in the evening |
| Night-time calf cramps | a painfully hardened muscle, no urge to move. See the question below |
| Habitual foot tapping | rhythmic tapping when bored or tense, without unpleasant sensations |
What Causes RLS, and What Can Make It Worse?
The exact cause is not known. According to the guideline, dopamine and iron metabolism play an important role. Often too little iron is available in the brain, even when blood tests show no iron deficiency. When RLS starts early in life, it often runs in the family.
The guideline no longer uses the old split into primary and secondary RLS. Instead, all accompanying conditions and factors that can make RLS worse shall be recognised and treated early. These include:
- Iron deficiency
- Pregnancy: according to IQWiG, RLS in pregnancy usually goes away by itself after birth.
- Chronic kidney disease and dialysis
- Thyroid disorders, which probably make RLS worse
- Neurological conditions such as Parkinson's disease or multiple sclerosis
- Certain medicines: according to the guideline mainly antipsychotics, plus some antidepressants; in isolated reports also antihistamines and anti-nausea medicines. Most people with RLS and depression, however, benefit from their antidepressant treatment
Do not stop any medicine on your own. Ask your doctor whether there is an alternative that worsens RLS less.
Diagnosis
The first tests can usually be done by your family doctor; for a detailed assessment you will often be referred to neurology or sleep medicine. Your doctor asks about your symptoms, other conditions and medicines. According to the guideline, everyone with RLS shall have their iron levels measured, meaning ferritin, transferrin saturation, iron and iron-binding capacity, plus a blood count. This applies at diagnosis, at the start of treatment and whenever symptoms get worse later. According to IQWiG, kidney and thyroid values are also measured.
Treatment
According to the guideline, whether medicines are needed depends on how much RLS affects sleep and quality of life. Long-term medication should start as late as possible.
Step 1: Treat triggers
Accompanying conditions such as iron deficiency, kidney or thyroid problems are treated first. Medicines that can worsen RLS shall be asked about and changed accordingly.
Step 2: Iron if ferritin is low
If ferritin is 75 µg/l or below, the guideline says iron tablets should be given first for mild RLS. For moderate to severe RLS, or if iron tablets are not tolerated, the guideline says an iron infusion should be given, in that case also if transferrin saturation is below 20 percent. Do not take iron on your own; only after your iron levels have been measured and in agreement with your doctor.
Step 3: Further medicines for severe symptoms
If iron is not enough or iron levels are normal, prescription medicines are an option. According to the guideline, treatment should start with a dopamine agonist, which mimics the effect of the messenger substance dopamine, or with a gabapentinoid. In Germany mainly the dopamine agonists are approved for RLS; gabapentinoids are used off-label. If these do not help enough in moderate to severe RLS, or if augmentation occurs, opioids are a second-line option. One slow-release opioid combination is approved for this in Germany; others are used off-label. Which active substance and which dose is your doctor's decision, in difficult cases ideally in neurology or sleep medicine.
Augmentation: with medicines that act on dopamine, symptoms can actually get worse over time. They then start earlier in the day, become stronger or spread to other parts of the body. According to IQWiG, this happens mainly when the dose is too high. To prevent it, the guideline recommends either using a gabapentinoid first or keeping dopamine medicines at the lowest possible dose. If it happens anyway, iron levels should be checked again first. If you notice this, talk to your doctor and do not raise the dose yourself.
What the guideline does not recommend
Magnesium, cannabinoids and benzodiazepines cannot be recommended for treating RLS. For acupuncture, pneumatic compression, laser treatment of the veins (endovascular laser ablation), cold therapy and herbal remedies, data are lacking, so they are not recommended at present either.
Without medicines
Non-drug options can be used alone or in addition. According to the guideline there is evidence of benefit for exercise training, such as yoga or cycling during dialysis, for infrared light and for a weak direct current applied through the skin of the back (transcutaneous spinal direct current stimulation). According to IQWiG, however, it is not yet clear how much they help.
What You Can Do
IQWiG lists things that many people with RLS find helpful in daily life:
- Home remedies: massaging, brushing or showering the legs, warm foot baths, wraps or compresses.
- Avoid coffee, nicotine and alcohol, especially in the evening.
- Wind down in the evening: no intense exercise, limit screens and excitement before bed.
- A calm sleeping environment: a comfortable temperature, darkness and regular sleep times.
- Movement and relaxation: stretching the legs, gentle exercises or relaxation exercises, and an iron-rich diet.
And before you take iron or anything else: have your iron levels measured first.
When to See a Doctor
- if restless legs regularly keep you from falling asleep or leave you exhausted during the day
- if symptoms start earlier in the day, get stronger or spread to the arms, especially while taking medicines
- if you have severe symptoms during pregnancy
- if you take medicines and suspect they make your symptoms worse
If, on the other hand, one leg suddenly swells and hurts, that is not RLS: see a doctor at once, it can be a deep vein thrombosis. For breathlessness or chest pain, call the emergency number at once (112 in Germany and the EU).
Frequently Asked Questions
What helps restless legs right away? Getting up and walking relieves the symptoms while you move. Many people also find massaging, showering the legs or a warm foot bath helpful. That does not help in the long run, though; if symptoms keep coming back, have your iron levels checked and the cause clarified.
Is iron deficiency the cause of RLS? Not always, but iron often plays a role. Often too little iron is available in the brain, even when blood tests show no deficiency. That is why, according to the guideline, everyone with RLS shall have their iron levels measured, and at a ferritin of 75 µg/l or below a doctor should give iron first.
Does magnesium help restless legs? According to the guideline, no: magnesium cannot be recommended for treating RLS. The same applies to cannabinoids and benzodiazepines.
Is RLS dangerous? RLS itself is not life-threatening, but it can seriously affect sleep and quality of life. Some accompanying conditions, such as iron deficiency or reduced kidney function, should be treated.
Does RLS go away after pregnancy? Usually yes: according to IQWiG, symptoms usually go away by themselves after birth. During pregnancy, too, the guideline says iron levels shall be checked and iron given if ferritin is 75 µg/l or below. Take medicines only after talking to your doctor, because many are not suitable in pregnancy.
Are restless legs and calf cramps the same thing? No. A calf cramp is a painful, hardened muscle contraction. In RLS the main feature is the urge to move the legs, without the muscle cramping. The guideline explicitly names calf cramps as something that must be distinguished from RLS.
What is augmentation? A worsening while taking medicines that act on dopamine: symptoms start earlier in the day, get stronger or spread. It happens mainly when the dose is too high. Then you should talk to your doctor and not raise the dose yourself.
How LEVANA Can Help
LEVANA does not make a diagnosis and does not replace a neurological assessment. In daily life the app can support you with reminders to move and with leg exercises.
Sources
All accessed on 6 October 2026. The sources are German; IQWiG is Germany's Institute for Quality and Efficiency in Health Care.
- AWMF S2k guideline Restless Legs Syndrome (030-081), German Society of Neurology and German Sleep Society, version 5.5, valid until 24 June 2027: diagnostic criteria, diagnostics, accompanying conditions (table 2), differential diagnoses (table 3), medicines that worsen RLS, treatment, augmentation
- IQWiG, gesundheitsinformation.de: Restless-Legs-Syndrom: symptoms, frequency, course, tests, treatment, everyday tips
- AWMF patient guideline Restless Legs Syndrome, 1st edition, August 2023
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Disclaimer
This article is for general information only and does not replace medical advice, diagnosis or treatment. If you have persistent or severe symptoms, please see a doctor.
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