Do You Have Restless Legs Syndrome (RLS)? Treatment Advice Has Changed

Restless legs syndrome (RLS) triggers an irresistible urge to move the legs to alleviate what some describe as a creeping, crawling, prickly, tingly sensation that bothers them when they are drowsy or resting.

For more than 20 years, the standard treatment has been dopamine agonists, drugs that mimic dopamine, a brain chemical that regulates movement. However, long-term data shows that while these drugs provide short-term relief, they often make RLS symptoms worse over time.

That’s the main reason why the American Academy of Sleep Medicine (AASM) overhauled its clinical guidance for treating RLS and periodic limb movement disorder (PLMD)—a similar condition that involves repetitive movements of the arms and legs during sleep.

The new guidelines downgrade a previous strong recommendation for dopamine agonists and conditionally recommend against their use. This means that dopamine agonists can still be used to treat RLS; however, they no longer should be the first medicine used. If they are prescribed, there should be close monitoring for a worsening of symptoms over time known as augmentation.

"Anyone with RLS who is taking a dopamine agonist should talk to their doctor about whether or not the medicine should be stopped,” says Brian Koo, MD, a Yale Medicine neurologist who serves as director of the Yale Medicine Restless Legs Syndrome Program. “The new guidelines are much better.”

Dr. Koo was on the task force that created the AASM guidelines, published in January 2025 in the Journal of Clinical Sleep Medicine. It was the AASM’s first update on the topic since 2012. The AASM issues “strong” recommendations to be followed in most circumstances and “conditional” guidelines that are considered less certain, suggesting the use of clinical judgment, and consideration of a patient’s values and preferences.

Specifically, the academy changed its previous strong recommendation for the use of dopamine agonists to a conditional recommendation against them in response to clinical trials, longitudinal studies, and the experience of doctors in the field showing the drugs cause augmentation. This affects medications including the drugs pramipexole (Mirapex®) and ropinirole (Requip®) among others.

“What really moved the needle on these drugs is an increase in the number of people who take them and develop augmentation,” Dr. Koo says. “It takes years to develop augmentation, but many of the patients who were started on these medicines in the early 2000s, when they were considered breakthrough medications for RLS, have been on them now for 20-plus years.”

Other new advice for RLS covers existing treatments that help many people manage symptoms. These include iron infusions for people found to have low levels of iron in the brain, a problem that has been linked to RLS and is suspected when blood tests show low iron levels in the body. Other therapies are a device that provides electronic stimulation for the legs and medications that ease RLS symptoms but do not cause augmentation.

We spoke to Dr. Koo to learn the most effective ways to manage RLS.

RLS, also known as Willis-Ekbom disease, is a neurologic condition and one of the most common sleep and movement disorders. It affects people of all ages—approximately 10% of adults in the United States have RLS (the prevalence may vary depending on factors such as age, gender, and ethnicity). RLS can be categorized as early-onset, with symptoms surfacing before age 45 and sometimes much earlier, or late-onset, beginning after age 45, when it tends to worsen more rapidly.

Relief is immediate with walking, stretching, or other movement, but the feeling can come back when those activities stop.

The exact cause of RLS has not been identified, but it is believed to have a strong genetic component—a significantly higher percentage of people who have a first- or second-degree relative with the condition develop it themselves. Women are significantly more likely than men to develop RLS, though the reasons why that’s so have not yet been nailed down. Many women develop the condition during pregnancy, but the symptoms often disappear after the baby is born.

RLS is linked to diabetes and kidney failure. Some medications, like antidepressants, antihistamines, and allergy drugs, can also cause it.

The new guidelines include conditional recommendations against treating RLS with dopamine agonists, which were considered breakthrough drugs for severe RLS when they were approved by the Food and Drug Administration (FDA) in the 2000s to treat the condition. These drugs work by activating dopamine receptors in the brain, but doctors and scientists do not know why they work for RLS. They include pramipexole and ropinirole among others, and transdermal rotigotine (Neupro®), which is administered through a patch on the skin.

But studies have shown that with continued use of this type of drug, a person whose worst bout of restless legs occurs at the end of the day may start to experience the problem both day and night, and the restless leg feeling can spread to the arms or trunk. Over time, the discomfort may become more intense, requiring more of the medication to control it.

“People get into real trouble when they take dopamine agonists long-term and start to need higher doses to ease their worsening symptoms,” Dr. Koo says. Elevated doses can cause problems like confusion, and psychiatric conditions such as depression and impulse control disorder—for example, some people start to experience compulsive shopping, gambling, and even hypersexual behavior.

"Sometimes when you talk to somebody on a high dose, they can't think clearly, and they become reactive and impulsive," Dr. Koo says. (It’s important to know that anyone experiencing augmentation should not stop taking dopamine agonists by themselves. They should only do this under medical supervision.)

Other approaches to treating RLS can go a long way toward managing the condition, says Dr. Koo. The following approaches may not be effective for everyone, but they often help, he adds.

• Lifestyle changes are the first step. Many sleep-related and environmental factors can trigger or worsen RLS symptoms. These factors include alcohol, caffeine, certain medications, and untreated obstructive sleep apnea. “Adjusting these is usually helpful and a good place to start,” says Dr. Koo, but may not solve the problem altogether.
• Iron deficiency testing is key. RLS is linked to low iron in the brain, which experts think may involve the body’s ability to process and deliver iron to the brain, Dr. Koo says. A blood test can check for iron deficiency; it should include a measure of serum ferritin levels, a marker for RLS. If levels are low, the treatment is typically intravenous iron supplementation, which is absorbed more rapidly than iron in pill form, according to the AASM.
• Gabapentin and similar medications can help some people. Experts gave strong recommendations for medications known as alpha-2-delta ligand calcium channel blockers: gabapentin enacarbil, gabapentin, and pregabalin. Unlike dopamine agonists, these drugs work by quieting the central nervous system and don’t cause RLS augmentation. "This can be very effective for restless legs, but when RLS is very severe, it often isn't enough," says Dr. Koo.
• Bilateral high-frequency peroneal nerve stimulation. This relatively new treatment for people with moderate-to-severe restless legs received a conditional recommendation from the AASM. The FDA approved the TX100 Tonic Motor Activation (TOMAC) System, a wearable device that stimulates the peroneal nerves in the legs (major nerves that branch off from the sciatic nerve) before bedtime. Data from clinical trials has shown that the device significantly reduces RLS symptoms, Dr. Koo says.
• Low-dose opioid medications. These drugs, which include oxycodone, received conditional support for cautious use in people with severe RLS. “We use low-dose, extended-release opioids,” says Dr. Koo. “While there is potential for addiction with any opioid, for RLS, the doses usually don't have to be escalated, and they certainly don’t need to be given at a high dose. Some people with severe RLS need them.”

Dr. Koo says that doctors can treat RLS, and a combination of approaches often works best. But it can be difficult to find specialized care for complicated cases, he adds. “The best type of doctor for this condition is a sleep neurologist. If you can’t find one in your area, go to a medical doctor who specializes in sleep disorders,” he says. Patients should be sure to tell their doctor if they have been taking dopamine agonists, he adds.

He also recommends that anyone seeking specialized care for RLS visit the website of the Restless Legs Syndrome Foundation, which has certified 13 quality care centers with expertise for complicated cases.

These centers include the Yale Medicine Restless Legs Syndrome Program and others in the U.S., as well as programs in Austria, and Switzerland. For people who don’t have access to a center, the national foundation can help locate a doctor who may not be associated with a quality care center but has experience treating RLS patients.