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Restless legs, akathisia and muscle cramps

The latest in our series offering evidence-based advice not covered by official guidelines

The latest in our series offering evidence-based advice not covered by official guidelines

Restless legs syndrome is a condition in which the patient experiences nocturnal, unpleasant sensations in the lower extremities alleviated by moving the legs. The condition may result in serious insomnia.

The differential diagnosis includes neuropathy, akathisia secondary to neuroleptics and nocturnal muscle cramps, which mainly affect the lower extremities.

Predisposing factors

Pregnancy, ageing, iron deficiency, uraemia and family history of similar symptoms are pointers to or causes of restless legs syndrome.

Akathisia usually begins immediately after or within a few weeks of starting a predisposing medication.

Electrolyte disorders (particularly hyponatraemia), dehydration, diuretics, leg oedema and denervation predispose to muscle cramps. Most patients suffering from muscle cramps do not have any known predisposing factor.


Clinical examination of the lower extremities should include an assessment for oedema, varicose veins, eczema caused by varicosis, patency of arteries, sense of touch and muscle atrophy.

If restless legs syndrome is suspected, serum ferritin should be checked. If the concentration is

in the lowest third of the reference range, iron supplementation may be beneficial. If necessary, serum creatinine should be checked.

In muscle cramps check serum sodium, potassium, magnesium, calcium, blood glucose, haemoglobin, haematocrit, total red cell count, and differential count.


41218441Instructions for improving sleep hygiene and iron supplementation are not always enough to calm restless legs. In mild cases a hypnotic or a low dose of benzodiazepine may be beneficial.

Potent, short-acting benzodiazepines should be avoided. The best effect has been obtained with small evening doses of dopaminergic drugs – pramipexole or ropinirole (level of evidence: C).

The side-effects of long-term therapy are not known. In severe cases opioids such as tramadol 50-100mg in the evening have been used. Gabapentin may be useful in painful cases.

If akathisia is suspected the provoking drug can be stopped or the dose reduced. If necessary a short course of propranolol 20mg x 3 or small doses of benzodiazepine may be used.

Passive stretching of the cramped muscle can be used as a first-aid measure. For prophylaxis all triggering factors should be eliminated. In severe cases, combinations including quinine sulphate (level of evidence: B) and diazepam or meprobamate can be considered. The patients must be followed up during the first weeks of therapy to evaluate the efficacy and adverse effects.

This synopsis is taken from EBM Guidelines, a collection of treatment and diagnosis guidelines supported by evidence summaries. © Duodecim Medical Publications. Distributed by Wiley-Blackwell. For more information, email or visit

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