Restless Legs Syndrome and Related Disorders - Medications

Antiseizure Agents

Antiseizure drugs, such as gabapentin (Neurontin), valproic acid (valproate, divalproex, Depakote, Depakene), and carbamazepine (Tegretol), relax blood vessels and are being tested for RLS. Gabapentin, a newer antiseizure drug, is showing particular promise for mild to moderate RLS.A well conducted 2002 study reported that it improved RLS symptoms and sleep, particularly in patients who also experienced pain. It was also effective for periodic leg movement disorder.

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Side Effects. All antiseizure agents have potentially severe side effects and should be tried only after non-drug methods have failed. Side effects of many anti-seizure agents include nausea, vomiting, heartburn, increased appetite with weight gain, hand tremors, irritability, and temporary hair thinning and loss (taking zinc and selenium supplements may help reduce this effect). Some can also cause birth defects and, in rare cases, liver toxicity. Gabapentin may have fewer of these side effects than valproic acid or carbamazepine.

Other Agents

Selective Serotonin Reuptake Inhibitors (SSRIs) and Similar Antidepressants. Imbalances in the neurotransmitter serotonin have been associated with RLS, and the common antidepressants known as SSRIs, which increase serotonin levels in the brain, may be tried. One study found that SSRIs reduced RLS in 58% of patients and eliminated symptoms in 12%. Oddly, however, RLS became worse in another 12%. SSRIs include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), fluvoxamine (Luvox), and citalopram (Celexa, Cipramil).

Bupropion (Wellbutrin), a newer so-called designer antidepressant that has slightly different actions, may also be helpful for RLS. These agents are not addictive and do not have the severe side effects of other RLS drugs, but more research is warranted to determine if they are useful.

Clonidine. Clonidine (Catapres), a drug used for high blood pressure, is helpful for some patients and may be an apt choice for patients who have RLS accompanied by hypertension. It also appears to be helpful for RLS patients who are undergoing hemodialysis.

Baclofen. The anti-spasm drug baclofen (Lioresal) appears to reduce intensity of RLS (although not frequency of movements).

What Are Nocturnal Leg Cramps?

Benign nocturnal leg cramps, sometimes known as a charley horse, are muscle spasms in the calf that can occur one or many times during the night. Cramping may also occur in the soles of the feet. They typically last from a few seconds to a few minutes. Some people experience them regularly; others only on isolated occurrences.

Causes of Nocturnal Leg Cramps

In many cases, the cause of nocturnal leg cramps remains unknown. Among the conditions that might cause leg cramps are the following:

Calcium and phosphorus imbalances can cause cramping, particularly during pregnancy. Imbalances in these minerals can also occur when fluid levels in the body become low, for example from taking diuretics, excessive perspiration, vomiting, or diarrhea.
Low potassium or sodium (salt) levels.
Deficiencies of a nutrient called hesperidin, an antioxidant flavonoid found in oranges and other citrus fruits, have also been linked to nocturnal leg cramps.
Overexertion, standing on concrete for long periods, or prolonged sitting (especially with the legs contorted) may contribute to nighttime cramps.
Having structural disorders in the legs or feet (such as flat feet) may increase the risk for cramps.
Among the many medical causes of muscle cramping include hypothyroidism, Addison's disease, uremia, hypoglycemia, anemia, and certain medications.Various diseases, such as Parkinson's, that affect nerves and muscles cause leg cramps. Peripheral neuropathy, a complication of diabetes in which the nerves in the extremities are impaired, can cause cramp-like pain, numbness, or tingling in the legs. Patients with kidney disease undergoing dialysis are also prone to leg cramps.

Individuals at Higher Risk for Nocturnal Leg Cramps

Nocturnal leg cramps occur at all ages but peak at different times. They are particularly common in adolescence, during pregnancy, and in older age, affecting up to 70% of adults over 50 at some point.

One study in campers reported an incidence of 7.3% in children older than eight; the incidence increased at 12 years old and peaked at age 16 to 18. Most of the adolescents with leg cramps reported that they had them one to four times per year.

Pregnant women and those taking diuretics are also at risk for leg cramps because of low calcium levels and an imbalance in calcium and phosphorus.

Consequences of Nocturnal Leg Cramps

Nocturnal leg cramps, like restless legs syndrome, rarely have any serious consequences. However, they can be extremely painful and long-lasting. In some cases, severe and persistent symptoms can cause chronic insomnia and considerable mental distress.

Managing Nocturnal Leg Cramps

Once a cramp begins, straighten the leg, flex the foot upward toward the knee, or grab the toes and pull them toward the knee.

Walking or shaking the affected leg, then elevating it, may also help.

If soreness persists, a warm bath or shower or an ice pack may bring relief.

Preventing Nocturnal Leg Cramps

Lifestyle Tips. Nighttime leg cramps are generally treated with lifestyle changes.

Everyone with leg cramps should drink plenty of water (at least six to eight glasses daily) to maintain adequate fluid levels.
Pregnant women and others who get legs cramps due to low calcium levels should reduce milk intake, because drinking milk does not correct the underlying imbalances in calcium and phosphorus. Instead, they should boost calcium levels by taking nonphosphate calcium supplements.
To prevent cramps from occurring, nightly stretching exercises may be the best preventive measure. Patients should stand about 30 inches from a wall and, keeping the heels flat on the floor, lean forward and slowly move the hands up the wall to achieve a comfortable stretch. A few minutes on a stationary bicycle at bedtime may also help.
While in bed, loose covers should be used to prevent the toes and feet from pointing, which causes calf muscles to contract and cramp. Propping the feet up higher than the torso may also help.
During the week, swimming and water exercises are a good way to keep muscles stretched, and wearing supportive footwear is also important.

Quinine and Tonic Water. The drug quinine may provide a slight benefit for reducing the frequency of leg cramps. It had been widely used to prevent leg cramping but was banned by the FDA for over-the-counter pharmacy sales because it was reported to cause some serious, although rare, side effects, including bleeding problems and heart irregularities. Other, less serious side effects include headaches, vision problems, and rash.

Drinking tonic water before bedtime may be helpful because it contains small amounts of quinine, a substance that may help reduce cramping. The small amount of quinine found in tonic water (the amount varies by brand) is generally considered safe and may provide some benefit, although pregnant women and those with liver problems should avoid quinine in any form.

Supplements. Some small studies indicate that the mineral magnesium, taken as magnesium citrate or magnesium lactate, may provide some benefit, including in pregnant women with leg cramps.

In one small study, taking vitamin B complex was helpful. Other supplements tried for leg cramps include vitamin E, calcium, and potassium or sodium chloride, but these do not appear to be very effective. Sodium chloride (salt) may be helpful, but Western diets in general already contain excessive sodium.