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Best treatments for the restless legs syndrome

RLS cannot be cured but the symptoms can be managed.

In both cases of chronic persistent RLS and intermittent RLS (see the "Diagnosis" page for definitions), non-pharmacological approaches should be used in the first instance to aid with the management of RLS.  For treatments of the acute (short-term) "creepy", "crawly", "aching" feelings in the legs visit the "Getting relief" page where therapies for immediate relief are discussed.  Preventative measures such as exercise and diet for RLS are discussed in the "Lifestyle" page.

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RLS can be treated. The goals of treatment are to:

  • Prevent or relieve symptoms.

  • Increase the amount of sleep you're getting and improve the quality of your sleep.

  • Treat or correct any underlying condition that may trigger or worsen RLS.

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No single medicine works for all people who have RLS.  It may take several changes in medicines and dosages to find the best approach.  Sometimes, a medicine will work for a while and then stop working or even make the symptoms worse (a phenomenon known as augmentation).
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For a comprehensive review on treatment strategies for RLS visit "An Updated Algorithm for the Management of Restless Legs Syndrome".

Treating intermittent restless legs syndrome

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The first step to treating intermittent RLS is addressing any iron shortfall. (see "Iron therapy" page)  For intermittent restless legs syndrome, before the doctor gets out the script pad, nonpharmacological strategies are used to alleviate the RLS symptoms.  The "Lifestyle" page discusses preventative strategies for RLS.  To alleviate the acute symptoms of RLS (see "Symptoms" page) some simple strategies (such as leg stretching, leg exercises, massage, hot and cold packs) can be employed (see "Getting relief" page for more options for reducing RLS symptoms).

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If nonpharmacological approaches prove ineffective then intermittent medication should be considered.  Medications can be used intermittently to prevent RLS that is known to occur in predictable circumstances such as plane flights, long car journeys, or audience situations such as concerts. They can also be used to treat RLS as soon as it occurs usually at night.

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A half or single tablet of carbidopa/levodopa 25/100 mg can be taken 30-minutes before activities known to precipitate RLS or as soon as an episode of RLS unpredictably starts.  During an episode continuing for several nights with RLS waking the patient after sleep onset, a single tablet of the controlled release form of carbidopa/ levodopa 25/100 mg can be used before bed.  For maximum effectiveness, levodopa should not be taken together with high-protein food.  Levodopa should never be used more than three times a week because of the very high risk of augmentation.

Box of Sifrol tablets

Dopamine agonists, such as pramipexole or ropinirole, can also be used intermittently but need to be taken 2-hours before the onset of symptoms.  Hence, their use is generally restricted to predictable sedentary situations known from experience to precipitate RLS.  They are not useful for unpredictable occurrences of RLS and therefore their usefulness in intermittent RLS is limited.

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For intermittent RLS an alternative to dopaminergic agonists are low dose opioids.  Codeine in doses of 30 mg to 90 mg or tramadol in doses of 50 mg to 100 mg are often effective.  As with levodopa, tramadol should not be used more frequently than three times a week, as regular use may also worsen RLS.

Figure 1: Sifrol (pramipexole)

Treating chronic persistent restless legs syndrome

Chronic persistent RLS is defined as symptoms occurring on average at least twice weekly for the past year.  Unlike intermittent RLS, in chronic persistent RLS if serum levels of ferritin are in the high end of normal and iron therapy is not warranted or iron therapy has failed to resolve the RLS symptoms then long-term medication strategies are employed.  The treatment decision making process for chronic persistent RLS is in Figure 1.

Treatment flow chart for RLS

A brief summary of Figure 1 is that all RLS patients should have serum iron levels.  If these are low-normal then oral iron therapy should be started (see iron supplementation protocols for circumstances of when to use oral iron and IV iron).  If iron therapy does not resolve the RLS symptoms then as a first line treatment gabapentinoids should be considered.  Circumstances where gabapentinoids should not be used, or at least used very cautiously, as a first line therapy​ are listed in Box 1.​​​​​​​​

Box 1: Gabapentinoids contraindications

  • Depression / anxiety

  • Falls risk / unsteadyness

  • Severe lung disease / sleep apnoea

  • History of severe weight gain or lower leg edema

  • Intolerance to Gabapentinoids

If gabapentinoids do not resolve RLS symptoms then other therapies should be used including Dopamine agonists, low dose opioids, Peroneal nerve stimulation or Dipyridamole.

 

For more information about treatments visit the "Updated Algorithm for the Management of Restless Legs Syndrome" and the "Treating RLS" section from the National Institute of Neurological Disorders and Stroke.

Do not begin, stop or change an RLS medicine or iron suppliment without advice from your doctor or pharmacist.

Last reviewed: 09/09/2026

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