Natural Remedies for Restless Leg Syndrome

Years ago, I noticed a curious thing:  my wife kicked me during the night.  Before you suggest that I deserved a good kick from her (I probably did), I  mean that her legs twitched, repeatedly, during the night.  In fact, her legs twitched every 18 seconds, like clockwork, over and over.  It turns out that my wife has something called Periodic Limb Movement Disorder (PLMD), which is considered by many to be an offshoot of Restless Leg Syndrome (RLS).

RLS was first described in the medical literature in 1672.  It is generally defined as the desire or urge to move the limbs (mostly legs), almost always when resting or trying to sleep. Symptoms are frequently associated with burning or tingling, and moving the legs, walking around etc. will usually temporarily relieve it.   RLS    occurs in 5-15% of the population, although it is apparently less common in African Americans than whites.  It appears to be more common in  women than men, and it can appear in childhood although it seems to be worse in older age groups. 

PLMD  was not recognized as a separate disorder until 1953.  Some researchers consider it to be an offshoot of RLS, while others describe it as a distinct condition.  There is definitely some overlap between the two, although RLS frequently includes tingling or other sensations, while PLMD is usually purely a motor phenomenon. 

RLS symptoms occur before going to sleep or after about 15-30 minutes of resting.   PLMD occurs almost exclusively during the first part of the sleep cycle during the first two sleep stages, and frequently is associated with a period of wakefulness or arousal.  This arousal does not have to be enough for the patient to actually be awake, and frequently patients don’t know they have limb movements unless told by their partner (like my wife).  Nevertheless, more than 5 arousals per hour, as measured in a sleep study, warrants intervention.   The periodic movements themselves can last a few seconds, and come every 5 to 90 seconds.   PLMD occurs more frequently with age.  Up to 30% of people over 50 have some form.

No one really knows what causes RLS and PLMD, but it seems to be associated with the circadian rhythm cycle,  the day-night rhythm that is built into our systems.  Specifically, the latter part of the rhythm is disrupted, and the majority of patients experience their symptoms between midnight and 3 AM.  The most studied cause of the disorders is a lack of the neurotransmitter (brain chemical) dopamine.  Dopamine is the neurotransmitter involved in controlling muscle movement, including involuntary movements.  Dopamine levels fall toward the evening and nigh, which matches the rhythm of RLS/PLMD.  The most important illness associated with dopamine deficiency is Parkinson’s Disease.  In fact, Parkinson’s and RLS are thought to be associated because of  this.

Not surprising, then, that Parkinson’s medications are frequently used in these conditions (RLS and PLMD are treated similarly so I’ll just refer to RLS).  Most Parkinson’s medications involve ways of boosting dopamine levels in the brain; they are called dopamine agonists. Common dopamine agonists include rotigitine, ropinirole, and pramipexole and, in fact, these drubs have been found to help RLS in randomized controlled studies.  The problem is the side effects.  Sedation is frequent.  I myself took ropinirole briefly for my Parkinson’s and walked around like a zombie.  Even more alarming is problems with impulse control.   Someone on these drugs could become addicted to gambling, drugs, sex, or even shopping.  Although it’s not been concretely proven, there is evidence of a genetic abnormality in RLS patients involving the gene that produced tyrosine hydroxylase, the enzyme that helps convert L_Tyrosine to dopamine.

Fortunately,  there are other ways of building dopamine in the brain.  Dopamine is made from the amino acid L-DOPA.  L-DOPA in turn is made from the amino acid L-Tyrosine.  Therefore, giving one or both amino acids is an indirect strategy for building dopamine (dopamine itself doesn’t cross the blood-brain barrier, so it has to be built up indirectly).

A decade ago, I ran across work by Dr. Marty Hinz, who was treating Parkinson’s and Restless Leg Syndrome by giving measured doses of L-Tyrosine (along with 5_Hydroxytryptophan or 5-HTP, an amino acid known for helping sleep) and Mucuna, an extract of the castor bean containing high amounts of L-DOPA.  I used his protocol successfully in some patients, but honestly it involved too many pills for a lot of people, and  the high amounts of L-DOPA caused a lot of queasiness and stomach upset.  Since then I’ve modified it to a smaller amount of amino acids, along with antioxidants (usually N-Acetylcysteine) and some vitamin B6.  It doesn’t work all the time, but it’s a lot safer than dragging someone out of a casino.

Another common way of treating RLS is by using anti-seizure drugs.  These medications, like gabapentin and pregabalin, lessen the transmission of nerves, leading to less stimulus to the muscle.  Like the dopamine agonists, they are not without side effects.   Any medication that sedates  nerves is bound to have a sedating effect generally, as anyone who has taken gabapentin for pain can attest.  Again, amino acids come to the rescue.  The amino acid L-Taurine can be an effective in situations where gabapentin is not tolerated.   I have used L-Taurine in patients with spasms, so-called clonic movements, and even seizures where they are not able to take medications.  Taurine has the effect of quieting down neurotransmitters, so it has a calming effect on the body as well.  For RLS and PLMD, I give L-Taurine at night and the L-Tyrosine combination in the morning since it can be stimulating (in fact, sometimes I use this for people who have a hard time waking in the morning).     Mucuna can be used at any time.

There is also evidence that depletion of iron stores in the body contributes to at least some cases of RLS.  These findings are probably not separate from the previous ideas, since adequate iron is necessary for proper function of the dopamine system, which in turn is critical in maintaining the proper circadian rhythm. MRIs have demonstrated less iron stores in the brains of RLS patients, and genetic investigation has suggested an underlying gene abnormality in at least some of  these patients.

Diagnosing iron deficiency can be tricky.  Recently a condition called iron deficiency without anemia, or IDNA, has been described.  In my experience patients with RLS in general are not anemic, and I  have only recently begun to look for IDNA.  However iron therapy can certainly be helpful in treating RLS, particularly in premenopausal women, who have a higher  risk of iron deficiency due to menstrual blood loss.  There have been several small  randomized controlled trials of iron and RLS, and though the results have varied there’s a trend toward iron being helpful in  relieving the condition.

Magnesium is another mineral that’s frequently used to treat RLS.  This is because magnesium generally relaxes nerve and muscle.  In this way it works similar to L-Taurine and , in fact, we use magnesium taurate  (a combination of the two) in situations from cardiac arrhythmia to muscle spasm to anxiety.  In this case magnesium can be used both orally before sleeping, and as a cream or lotion to rub on the feet and legs at night.  Although studies again have been few and far between, this is time-honored treatment for leg spasms of all kinds, and certainly is worth a try.  Interestingly, a study of trace minerals in RLS showed higher than normal levels of magnesium (along with calcium, selenium and copper) in the serum, though magnesium actually does its work within the cell, and high serum levels sometimes can indicate that the magnesium is not going where it’s supposed to.

Melatonin, the hormone responsible for the circadian rhythm, actually inhibits dopamine secretion and vice versa.  Thus, there is a theory that giving melatonin can worsen RLS, and that light therapy (shining bright light, particularly in the eye) can improve it.  A small (8 patient) study seemed to bear this out, and we discourage the use of melatonin in RLS.  Light therapy on its own has been studied, particularly a device giving near-infrared (NIR) light in pulses over the legs, encompassing 57 subjects in total, and the study was positive, the effects even lasting for weeks after the light therapy was ended.

 Antioxidant nutrients  (E, C, CoQ10) have not been clinically studied (except for a small, positive study of Vitamin E in RLS patients with kidney disease).  But, the theory that oxidative stress causes damage to the dopamine-producing cells of the brain has led to a common suggestion that these nutrients be tried in RLS.  More evidence exists for the use of Vitamin D, which is known to protect dopamine-producing neurons against toxins.  Vitamin D deficient patients have a higher rate of RLS ,and in a small study of vitamin D deficiency and RLS, supplementing with Vitamin D improved symptoms.   Not many botanicals have been studied in RLS, but valerian, an herb with Valium-like effects, was studied in a randomized controlled study of 37 RLS patients.    Both valerian and placebo improved the symptoms, but valerian did better.

And my wife?  She still kicks me occasionally, but only when she has a reason.

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