When Sleep Will Not Settle: Understanding Restless Legs Syndrome

I used to think bad nights were simply about willpower—count to a hundred, turn the pillow, negotiate with the dark. Then the nights began to twitch beneath the sheets. A quiet electricity stirred in my calves like wind worrying a field, and stillness—something my body once understood—slipped from reach. Rest became a moving target. Peace became a verb.

Tonight, I want to tell the truth about that movement. Not as a mystery to fear, but as a map to read: what it feels like from the inside, what science now understands, how doctors recognize it, and how I learned to build a steadier night from simple foundations—iron, light, timing, and care.

What It Feels Like From the Inside

There is a particular restlessness that arrives the moment I try to be still. It begins as an urge—strong, insistent—to move my legs. The sensation is hard to name, more texture than pain: crawling, fizzing, tugging, a deep itch that refuses the skin's surface. When I flex my ankles or stand to walk the hallway, relief comes quickly, but only for a brief window. The pull returns the moment I stop.

This pull obeys its own clock. It grows louder in the evening, especially when I sit to read or lie down for sleep. During the day I can negotiate with it. At night, it bargains me into circles—up, down, back to bed again. The more I resist, the more I learn the lesson that movement, paradoxically, is the only stillness that works.

Why It Happens: Current Science

Researchers describe Restless Legs Syndrome (RLS) as a neurological condition with roots in how the brain regulates movement and sensation. A central insight of the last decade is the role of iron in the brain's circuits. Even when iron in the bloodstream looks "normal," the brain's iron can run low; when that happens, the pathways that use dopamine—our fine-tuning signal for motion—can misfire, and the body translates that misfire into an urge to move.

Genetics can be part of the story, too. If my parent or sibling knows these evening impulses, my odds rise. But genes are not destiny. The body is a system of levers and context. Pregnancy, chronic kidney disease, low iron stores, untreated sleep apnea, some medications, and even simple sleep loss can nudge symptoms from quiet to loud.

How Doctors Diagnose RLS

There is no single lab that "proves" RLS. Instead, clinicians rely on a set of core features: an irresistible urge to move the legs (often with unpleasant sensations), symptoms that begin or worsen at rest, relief with movement, and a pattern that is worse in the evening or night. They also make sure the sensations are not better explained by another problem like leg cramps, arthritis, or venous issues.

Because iron matters, blood work to check iron status is routine—especially ferritin (the body's iron storage) and transferrin saturation. A sleep study isn't always necessary unless the picture is unclear or another sleep disorder is suspected.

Common Triggers and Risk Factors

Some patterns keep showing up: symptoms often intensify with caffeine, alcohol, nicotine, and certain medications (notably sedating antihistamines and some antidepressants). Pregnancy can temporarily amplify RLS. Medical conditions such as iron deficiency, kidney disease, neuropathy, and uncontrolled sleep apnea can worsen the picture. Women are affected more often than men, and while RLS can begin at any age, it tends to become more disruptive with age.

Prevalence figures vary by study, but the condition is common. A meaningful minority of adults will meet criteria at some point in life, and a smaller group experiences symptoms severe enough to regularly disrupt sleep and daytime function. Knowing this doesn't erase the difficulty—but it replaces isolation with context.

Home Foundations That Help

Before I ever talk about medicine, I work on the ground floor—the daily levers within reach. I build a steady sleep window (consistent rise time wins), dim bright screens in the last hour, and shift heavy meals earlier so my body isn't multitasking at midnight. I minimize evening caffeine and alcohol. Gentle, regular exercise helps, especially if I schedule it earlier in the day and leave space for the body to cool before bed.

When the sensations climb, I use movement as a tool rather than a failure: a few minutes of calf stretches, a slow walk down the hallway, a short session on a stationary bike. Warm soaks or alternating warm and cool compresses can settle the edges. None of these erase the condition, but together they buy back minutes that add up to hours.

I stand in the dim hallway, slow breath rising as the urge softens.

Iron and Nutrition: The Ferritin Story

Iron is not only about muscles and blood; it is a language the brain uses to coordinate motion. That is why clinicians often check ferritin and, when stores are low for RLS needs, replenish them. For some people, oral iron taken with vitamin C can raise ferritin adequately over weeks. For others—especially when symptoms are more severe or oral iron isn't tolerated—intravenous iron can provide a steadier, quicker response.

I learned to treat nutrition as support, not cure. A balanced pattern with iron-rich foods, enough protein, and mindful timing of calcium and caffeine (which can interfere with absorption) helps the supplements do their work. The goal is not just "normal" lab values but levels sufficient for calmer nights.

Medication Options: Benefits and Trade-Offs

When symptoms persist despite good foundations, medication can help. In recent guidance, medicines that act on calcium channel "alpha-2-delta" receptors—gabapentin, gabapentin enacarbil, and pregabalin—are preferred due to a favorable balance of benefit and long-term safety for many adults with RLS. These can cause sleepiness or unsteady gait, so dosing and timing are individualized with care.

Older mainstays called dopamine agonists (such as pramipexole, ropinirole, or rotigotine) can be very effective early on, but they carry a well-documented risk of "augmentation," where symptoms start earlier in the day, spread, and grow more severe over time. Because of that risk, routine long-term use is now generally discouraged in favor of safer first-line options, reserving them for specific situations with close monitoring.

Iron therapy is elevated to center stage when labs support it, including intravenous ferric carboxymaltose in select adults. For truly refractory cases, carefully supervised low-dose extended-release opioids can reduce symptoms, though risks demand expertise and caution. Sedatives like clonazepam may aid sleep for some but are not favored as primary RLS treatment because benefits are limited compared to the risks.

RLS vs. Periodic Limb Movement Disorder

RLS describes how I feel when I am awake or trying to fall asleep: the urge that drives me to move for relief. Periodic Limb Movement Disorder (PLMD) describes movements that happen during sleep—brief, repetitive jerks or flexes that I may not notice at all. The two conditions frequently travel together, but they are not the same.

In RLS, movements are a voluntary response to an uncomfortable sensation; in PLMD, the movements are involuntary and detected on a sleep study. Both can fragment sleep. Distinguishing them matters because treatments and expectations differ.

Living Well When Nights Are Restless

What keeps me steady is a plan I can follow when symptoms rise. I keep evenings simpler. I set travel days with leg-friendly breaks and pick aisle seats for easy walking. I practice saying "I need a short stretch" without apology in long meetings. I let loved ones know what helps and what does not—pressure to lie still never helps; quiet company often does.

Progress, for me, is a gentler arc: fewer awakenings per week, shorter detours out of bed, a softer morning in my chest. RLS does not define my nights, but it reshapes them. With the right levers—iron, movement, light, and medicine when needed—I can still choose a kinder rhythm.

Mistakes & Fixes

It took time to recognize the traps. These are the patterns I correct when my nights start to fray.

The posture that helps is humble and practical: act early, measure what matters (sleep window, ferritin goals, medication timing), and adjust gently before the spiral grows.

• Relying on willpower alone. Fix: Treat the urge as a signal, not a failing. Move briefly, then return to bed with a plan.
• Late caffeine and screen glow. Fix: Cut afternoon caffeine; dim devices in the last hour and favor audio over scrolling.
• Skipping iron labs. Fix: Ask for ferritin and transferrin saturation; treat low stores to RLS-appropriate targets.
• Sticking with a med that backfires. Fix: If symptoms creep earlier or spread, talk about augmentation and alternatives.

Mini-FAQ: Short, Clear Answers

Here are brief answers I wish I had sooner—practical enough to use tonight.

They are not rules, but levers. Use what fits your body and your life, and revisit choices when your days or health change.

• Is RLS forever? It is a chronic condition for many, but symptoms often wax and wane. With the right foundations and treatment, nights can improve markedly.
• Does exercise help? Yes—gentle, regular activity helps, especially earlier in the day. Avoid intense workouts late in the evening.
• Which meds can make it worse? Sedating antihistamines and some antidepressants can exacerbate symptoms. If mood treatment is needed, options like bupropion may be considered under medical guidance.
• What iron level should I aim for? Discuss RLS-appropriate targets with your clinician; ferritin levels considered "normal" for the general population may still be suboptimal for RLS.
• How is PLMD different? PLMD movements occur during sleep and are involuntary; RLS urges are felt while awake or falling asleep and ease with movement.

References

American Academy of Sleep Medicine (AASM) Clinical Practice Guideline for RLS and PLMD, 2024–2025.

RLS Foundation, Updated Management Algorithm (Silber et al.), 2021.

Mayo Clinic, Restless Legs Syndrome Overview, 2025.

International RLS Study Group (IRLSSG) Diagnostic Criteria Update, 2014.

Song et al., Global Prevalence of RLS (adult estimates), 2024.

Silber, Bringing Iron to the Brain for RLS (ferritin guidance), 2025.

Disclaimer: This article shares general information and lived experience. It is not medical advice and does not replace care from your clinician. If symptoms disrupt your sleep, mood, or safety—or if you are pregnant, managing chronic illness, or considering medication changes—consult a qualified health professional.