As answered by our issue reviewers.
Question: Can taking iron cure my Restless Legs Syndrome (RLS)?
Dr. Zak: Before answering this question, I want to address the terms. You have asked about “curing” RLS. RLS is not like an infection where there is a medication (an antibiotic, for example) and once taken, the infection is “cured”. Consider it more like hypertension, a clinical disorder that needs to be managed.
That being said, RLS tends to occur in individuals with a genetic predisposition in the setting of low brain iron such that restoring that state can eliminate the symptoms. Therefore, the answer to your question is actually “yes” and “no”. It is “yes” if the low brain iron is occurring for a specific and limited reason, such as insufficient iron in the diet or an episode of acute loss of blood, such as blood loss from surgery or frequent blood donations.
In these cases, once the iron loss is corrected, you can return to an RLS-free state. However, many people we see require higher levels of blood iron than they have at baseline to overcome the symptoms. These individuals need to have iron therapy long-term, which to me would say that it is not so much a cure as a treatment. Still others get no relief or only partial relief of RLS symptoms with iron alone and require another medication, such as pregabalin, or behavioral treatment, such as warm soaks before bedtime.
Dr. DelRosso: Iron supplementation improves symptoms of RLS but it’s not curative. The symptoms of RLS can be exacerbated by many other factors (use of caffeine, medication effect, lack of exercise, presence of another disorder or condition, among others) so treatment and evaluation of RLS should be comprehensive and done by a sleep professional.
Dr. Lipford: If you are iron deficient, a course of iron supplementation can help reduce (and in some cases resolve) RLS symptoms. In general, oral iron supplementation is used. However, in some cases (such as severe iron deficiency or intolerance/difficulties absorbing oral supplements) IV iron treatments may be recommended. Combining an iron supplement with vitamin C can increase absorption, and iron supplements should ideally be taken on an empty stomach. It can take a few months after starting an iron supplement to see improvements in RLS symptoms.
It is also important to know that too much iron can be bad for our health, so you should not start taking an iron supplement without talking to your doctor. If you are iron deficient, your doctor may want to do additional tests to figure out why and your doctor will guide you on the best way to take iron supplements.
Dr. Thomas: In most instances, RLS occurs in individuals with a deficiency in brain iron, specifically, in the part of the brain that is involved in rhythmic activity. It is unclear why there is reduced brain iron, but it may involve abnormal transport of iron into this area, or abnormal storage/binding. There are animal models of iron deficiency and RLS, making it more certain that iron is critical. There is also a delicate balance of three neurotransmitters (brain chemical information messengers) involved in RLS – adenosine, dopamine, and glutamate. A normal balance requires iron. If iron deficiency in the body caused RLS, such as severe blood loss, then iron replacement could potentially cure RLS. In most instances, there is normal blood/ liver/gut/bone marrow iron but reduced brain iron.
Iron replacement (oral) helps if there are low ferritin (a measure of iron stores) levels, but otherwise intravenous (IV) iron is needed, which bypasses the block of iron absorption when the non-brain iron is normal. IV iron raises levels for several weeks to months and allows the brain to slowly take up what is needed. There is probably no real cure, and sometimes there is a need for repeat IV iron. Not all IV iron preparations are equal for the brain.
Question: What other options, besides medication, are there for treating RLS?
Dr. Lipford: There are lots of ways to reduce RLS symptoms that don’t involve medications. A very effective technique is to incorporate moderate exercise into your daily regimen. This could be as simple as taking an evening stroll. Experiment with the type and timing of exercise to see what works best to alleviate your RLS symptoms. Warm soaks or using a hot tub in the evening can be helpful. Additionally, many people with RLS find massaging the legs and stretching every night before bed to be useful. Avoiding caffeine and alcohol in the evenings can also help.
Dr. Zak: Wonderful question! As above, we generally begin with assessing iron levels and ensuring not just “normal” iron storage but more mid-normal to high-normal iron storage (we often follow ferritin levels, a measure of iron storage rather than just iron levels since iron levels are dependent on the time of day and immediate ingestion).
In addition to iron, one can try “counter stimulation methods”, which often consist of warm soaks before bedtime, stretching or rubbing the legs–anything that applies pressure to the legs. There are devices one can try that provide stimulation to the legs as well, which work for some people and not for others. We also recommend avoiding aggravating factors such as caffeine and alcohol and watching the effect of timing, amount, and type of exercise on the RLS symptoms.
Dr. Thomas: Temperature (whatever helps, warmer or colder), vibration devices (one was pulled from the market due to lack of medical (vs. “cosmetic”) approval, transcutaneous electrical nerve stimulation – such approaches should have a medical doctor guiding you.
Dr. DelRosso: Exercise seems to improve symptoms. Also, avoidance of substances known to make the symptoms of RLS worse. Some people recommend massage or stretching before bedtime.
Question: When I sleep, I am often awakened with severe leg cramps. What can I do throughout the day to ensure this does not occur at night?
Dr. DelRosso: Drink plenty of fluids to avoid dehydration. Massage and stretch your legs before bedtime. Avoid tight-fitting socks or clothing, including tightly tucked-in bedsheets.
Dr. Zak: Leg cramps are such a painful and frustrating problem. They can be caused by being dehydrated so ensuring adequate hydration is important. For some patients, the leg cramps can come in the setting of abnormal calcium and magnesium levels so ensuring that these are normal is sometimes helpful. Try stretching the legs before bedtime (since cramps are often in the calves, stretching the calves is generally recommended and there are a variety of standing exercises that are suggested). Some people find vitamin B complex and vitamin E helpful. If these measures do not work, there are prescription medications that can be helpful and best discussed with your primary care provider.
Dr. Thomas: Hydration and “ionic balance” (potassium, sodium, and especially magnesium) can help prevent leg cramping at night. It is also important to avoid intermittent random over-exertion. Over-the-counter magnesium oxide at bedtime could help. Tonic Water (used, for example, to make “Gin and Tonic”) has quinine which reduces cramps, but if used should be under medical supervision. There are some muscle disorders where cramping is a key symptom and may require medications to “calm” the nerves supplying the muscle. Dr. Lipford: Nighttime leg cramps can be a frustrating problem. Staying well-hydrated throughout the day can help to reduce the frequency of cramps. Additionally, stretching the legs before bed can be beneficial. You might also want to try a warm soak prior to bed. If the cramps persist, check-in with your doctor to see if there are any electrolyte deficiencies that could be contributing, or if the cramps could be related to any of the medications you are on.
Question: My child grinds his teeth all night long. How do I know if it is more than typical childhood teeth grinding?
Dr. DelRosso: In many cases, treatment of bruxism is unnecessary, and children outgrow bruxism. However, I usually recommend an evaluation by a dentist to assess if any dental issues could be contributing to bruxism. Also, if symptoms of another sleep disorder are present, such as snoring, an evaluation by a sleep physician may be necessary. Keep an eye on activities during the day that have been associated with bruxism, such as nail-biting or pen biting, and discuss with your pediatrician options to stop these activities.
