Why do my legs feel restless or hurt at night?

An urge to move the legs that starts at rest, is worst in the evening and at night, and eases while you walk is the pattern of restless legs syndrome. Legs that cramp with a visible, painful contraction, burn or go numb regardless of movement, or ache after walking point to cramps, neuropathy, or circulation problems instead, and a neurologist can tell these apart from the history.

What helps restless legs at night?

In the moment, walking, stretching, massaging the legs, or a warm bath. Longer term, correcting low iron stores, stopping a medication that triggers it, keeping caffeine and alcohol out of the evening, and, for frequent symptoms, a medication such as gabapentin chosen by your doctor. What helps most depends on the cause, which is why the ferritin level and the medication review come first.

What type of doctor treats restless legs syndrome?

A neurologist or a sleep medicine specialist. Many people start with their primary care doctor, which is reasonable for a first ferritin check. A neurologist is the right next step when the diagnosis is uncertain, when iron replacement has not helped, when a medication may be the trigger, or when symptoms are getting worse on treatment.

What is the connection between iron and restless legs?

Brain iron is needed to make dopamine, and low brain iron is strongly linked to RLS even when blood counts are normal. A neurologist checks ferritin, the storage form of iron, and transferrin saturation. The American Academy of Sleep Medicine guideline recommends iron replacement when ferritin is 75 ng/mL or lower, or transferrin saturation is under 20 percent, and intravenous iron when ferritin sits between 75 and 100. Those are levels most routine lab reports would call normal.

Can restless legs syndrome be cured?

Secondary RLS, caused by iron deficiency, pregnancy, kidney disease, or a medication, can resolve completely once the cause is dealt with. Primary RLS is usually chronic, but it is well controlled in most people, with the treatment adjusted over time as symptoms change.

Does restless legs syndrome happen in pregnancy?

Commonly, most often in the third trimester, and it usually resolves within days of delivery. Iron demands are high in pregnancy, so checking ferritin is particularly worthwhile. Treatment choices are more limited during pregnancy, which is a good reason to have it managed rather than endured.

When should I see a neurologist for restless legs?

See a neurologist if symptoms occur twice a week or more, disrupt your sleep, cause daytime fatigue or concentration problems, or are getting worse on treatment. A neurologist confirms the diagnosis, rules out the conditions that imitate it, checks iron stores, and sets up a plan.

Restless Legs Syndrome (RLS): Causes, Iron and Treatment

Restless Legs Syndrome: Causes, Symptoms, and Treatment Options

Restless legs syndrome is an urge to move the legs, usually with a crawling or aching feeling, that starts at rest, is worst in the evening and at night, and eases while you move. It is diagnosed from the history, and the first test is a ferritin level, because low iron stores are the most treatable cause. Iron replacement, stopping medications that worsen it, and when needed a medication such as gabapentin control symptoms in most people.

Medically reviewed by Dr. Achillefs Ntranos, MDPublished September 14, 2024Updated September 3, 202610 min read

A seated person's legs and feet beside a quiet nighttime window.

Restless legs syndrome is easy to recognize once you know the pattern and easy to miss when you do not, which is why so many people are told their legs are just cramps, or just anxiety, for years. It is also one of the more satisfying conditions in neurology to treat, because a careful history and one blood test often lead to nights that are genuinely better within weeks.

How to know it is restless legs

The diagnosis rests on four features. All four have to be present, and when they are, no scan or nerve test is needed to make the call.

Feature	What it means in practice
An urge to move	A need rather than a pain, often with a crawling, pulling, or fizzing feeling that is hard to describe
Brought on by rest	It starts when you sit still or lie down, not when you are busy
Relieved by movement	Walking or stretching helps, and only for as long as you keep moving
Worse in the evening	Reliably worse at night than at the same rest in the morning

Most people with RLS also have periodic limb movements in sleep, repetitive leg jerks that a bed partner usually notices first. Some feel it in the arms as well, and a few describe an ache rather than an urge, which is why legs that hurt or will not settle at night are worth describing precisely rather than dismissing as cramps.

Legs resting at the bedside and legs walking in an evening bedroom scene. — Symptoms tend to appear at rest and improve while moving.

What is behind it

Genetics. RLS runs in families, and the earlier it starts, the more likely a relative has it too. There is no genetic test used in practice.
Brain iron. Iron is required to make dopamine, and low brain iron is the mechanism behind a large share of cases. Ferritin can sit comfortably inside the reference range on a routine report and still be far too low for someone with RLS.
Medications. Several antidepressants, sedating antihistamines, and anti-nausea drugs trigger or worsen RLS. A medication review is one of the first things we do, and sometimes the only thing needed.
Other conditions. Kidney failure, diabetes, peripheral neuropathy, and Parkinson's disease all raise the risk.
Pregnancy. RLS commonly appears in the third trimester and usually settles after delivery.

Conditions that imitate it

Condition	How it differs from RLS
Peripheral neuropathy	Burning or numbness that does not ease when you walk, and no evening pattern
Nocturnal leg cramps	A painful, visible muscle contraction lasting seconds to minutes, not an urge
Akathisia	Whole-body restlessness driven by a medication, without the evening timing
Circulation problems in the legs	Pain brought on by walking and relieved by rest, the reverse of RLS

What the visit adds

The diagnosis is made from your description, and the examination is usually normal. What an evaluation contributes is confirming all four features are present, excluding the look-alikes above, and finding the causes that can be corrected.

Expect a detailed history of the timing and the family pattern, a neurological examination looking mainly for neuropathy, blood tests including ferritin, transferrin saturation, and kidney function, and a line-by-line review of every medication and supplement you take. A sleep study is worth doing only when the sleep disruption seems out of proportion to the RLS, to check for sleep apnea underneath it.

Preparing for a restless legs appointment

Because the diagnosis comes from the history, what you bring matters more than for most conditions. A week of notes is enough.

The timing. What time of evening it starts, how many nights a week, how long it keeps you from sleeping, and whether it happens during long car or plane journeys.
What it feels like, in your own words, and what relieves it: walking, stretching, a hot or cold shower, rubbing the legs.
Every medication and supplement, including over-the-counter sleep aids and allergy tablets, which are among the most common triggers.
Previous blood results, especially any ferritin or iron level, even if you were told it was normal.
Family history, and what a bed partner has noticed: leg jerks, kicking, snoring, or pauses in breathing.
Anything relevant to iron: heavy periods, pregnancy, frequent blood donation, kidney disease, or a vegetarian diet.

If you are already taking something for it, say what and how the pattern has changed, because symptoms that have crept earlier in the day or spread to the arms change the plan.

Evening symptom diary beside a medicine container and blood sample tube. — A clear symptom history and medication list make the evaluation more useful.

Treatment

Correcting the cause comes first. Medication follows only when symptoms are frequent enough to cost you sleep or evenings.

Iron replacement, oral or intravenous, when ferritin or transferrin saturation is low. This is the first step and the one most often skipped. It takes weeks to months to show its full effect.
Removing the trigger, meaning changing a medication that is worsening the RLS where an alternative exists.
Lifestyle measures that genuinely help mild cases: a regular sleep schedule, moderate exercise but not intense exercise late in the day, less caffeine and alcohol in the evening, and stretching, a warm bath, or leg massage before bed.
Alpha-2-delta medications such as gabapentin or pregabalin, now the usual first choice for daily symptoms.
Dopamine agonists, which the 2025 American Academy of Sleep Medicine guideline now recommends against for routine use because of augmentation. They are reserved for specific situations rather than started by default.
Opioids, reserved for severe cases that have not responded to anything else, with close monitoring.

If your restless legs are getting worse on treatment

Symptoms that start earlier in the day, spread to your arms, or intensify while you are on a dopamine agonist are usually augmentation caused by the medication rather than the disease progressing. Do not increase the dose on your own. The fix is almost always to change the medication, not to add more of it.

When to see a neurologist

See one if symptoms happen twice a week or more, if they are costing you sleep or making it hard to concentrate the next day, if they started or worsened after a new medication or during pregnancy, if they are getting worse on treatment, or if you are simply not sure whether this is RLS or something else.

RLS is one of the conditions best suited to video, because the diagnosis is made from the history. A first visit with Dr. Achillefs Ntranos, MD is 60 minutes, by video anywhere in California or in person in Beverly Hills or Los Angeles. We confirm the diagnosis, review your medications, order iron studies, and start treatment when the picture is clear. Follow-up is by message or a short video visit while we adjust the plan. You can book a visit with no referral needed.