Dr Ginevra Liptan
By Ginevra Liptan, MD
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The throbbing, pulling or creeping sensations of Restless Legs Syndrome (RLS) can be miserable—and affect at least one third of all women with fibromyalgia. These uncomfortable feelings and urge to move the legs are often triggered by trying to relax or sleep, making it hard to fall and stay asleep. And it is not just the legs, some people experience the restless sensations in their arms or over their whole body! Since sleep is already a huge issue in fibromyalgia, it is really important to be look for and treat any condition that is making sleep worse.
If you answer yes to any of these questions, you may have Restless Legs Syndrome:
o Do you often get a strong urge to move your legs to relieve unpleasant sensations?
o Are the symptoms worse when you’re sitting still or lying down and resting?
o Do you get temporary relief from moving your legs or walking?
o Do the symptoms start or get worse in the evening or at night?
There are definitely medications that can help ease these symptoms, but many of them have significant side effects. Some very effective natural treatments for Restless Legs Syndrome to consider are iron, magnesium and cannabidiol (CBD).
Iron for Restless Legs
We know that restless legs is caused by low levels of the brain chemical dopamine, and many of the prescription treatments for RLS act to increase dopamine levels. Iron is a key player in the production of dopamine, so low iron levels in the brain may lead to low dopamine levels and restless legs symptoms. There has long been a suspected connection between low iron levels and RLS, and people with iron deficiency anemia often experience restless legs symptoms. However people with normal iron blood levels can still experience RLS, and it appears that it is the level of iron that reaches your brain that matters, not the amount floating in your bloodstream. One of my patients with severe RLS and normal blood iron levels had her symptoms eliminated after a series of intravenous (IV) iron infusions, which is the most effective way to get iron into the brain. One study found that IV iron infusions showed significant improvement of RLS symptoms in 76% of the subjects without any major side effects.
For patients with RLS I aim to get their ferritin levels (a blood test for iron) around 70 to maximize how much iron is getting into their brain. Typically any ferritin above 10 is considered “normal”, but if you have RLS it is worth a try to get your ferritin levels up into “optimal” range and see if symptoms improve. In my clinical experience, the results can be pretty dramatic, but be sure to talk with your health care provider before starting iron supplementation as your levels will need to be monitored to ensure they don’t get too high as that can be harmful. You want to find the amount of iron supplementation that keeps your ferritin around that optimal level of 70.
Some forms of iron can be hard on the stomach and cause nausea and constipation. I have found iron bisglycinate to be the best tolerated, my favorite is Opti-feren C by Pure Encapsulations. To optimize iron intake make sure to take it away coffee, tea, and calcium supplements as these can interfere with iron absorption. I often recommend taking any iron with dinner as most of us are not drinking coffee with dinner!
An alternative approach for those that don’t tolerate or absorb oral iron is to apply it transdermally. Yes, we can absorb some iron through our skin! Compounding pharmacies can make a prescription iron cream, although a few of my patients found it discolored their skin. For topical iron I prefer the PatchMD Iron Plus Topical Patch as it is less messy, cheaper, and has no skin discoloration issues.
In addition to getting ferritin levels up to optimal range, for those with severe RLS I will often add some specific nutrients that increase the ability of the body to utilize iron, like the active forms of B-6, B-12, and folate, found in MethylGuard by Thorne Research. For this purpose I have patients just add one capsule of MethylGuard per day.
Magnesium for Restless Legs
Magnesium is another beneficial mineral that can help RLS. Clinically I see this all the time and this study found it was effective for mild to moderate symptoms. Magnesium promotes muscle relaxation and soothes irritable nerve endings. The best form of magnesium for this purpose is magnesium glycinate 240mg to 480mg at bedtime. Magnesium glycinate is the type least likely to cause loose stool, one common and undesirable side effect of magnesium supplementation. Just like iron, we can absorb magnesium through our skin, so you can also apply magnesium oils and lotions directly to your legs. Remember that magnesium is a salt, so some oils can be irritating to the skin. My goal with Frida Botanicals magnesium cream was to make a potent cream that was still gentle and moisturizing. Some of my patients have found that a combination of oral and topical magnesium is the ticket to ease their restless legs symptoms while limiting the laxative effect.
Cannabidiol (CBD) for Restless Legs
Many patients have reported that cannabis (marijuana) eases their restless leg symptoms. This small study found 6 patients reported complete remission of their RLS with cannabis. Cannabis contains lots of different chemicals, so it is unclear which are specifically giving benefit for RLS, but CBD (cannabidiol), is suspected to be the key component of cannabis for RLS. In fact an Israeli company is currently studying CBD as a treatment for Restless Legs Syndrome.
CBD has strong muscle relaxant and nerve calming effects which can really ease the discomfort of restless legs. And just like iron and magnesium, CBD can be taken orally or applied topically to the legs. I have seen patients get improvement from CBD applied topically or a CBD tincture under the tongue before bed. And unlike cannabis, CBD does not have any psychoactive or mind-altering effects and if it is derived from hemp it is legal and accessible in all 50 states. If you want to learn more about CBD safety, effectiveness and dosing check out my other blogs here and here and my videos below.
The throbbing, pulling or creeping sensations of Restless Legs Syndrome (RLS) can be miserable—and affect at least one third of all women with fibromyalgia. Learn how iron, magnesium and CBD can help.
Restless Legs Syndrome: Medical cannabis as a therapy option
People with restless legs syndrome (RLS) complain of a strong urge to move their legs at night. Mostly also about tingling and aching legs. This is known as restless legs syndrome (RLS), a frequently occurring neurological disease.
The study situation regarding the therapy with medical cannabis for movement disorders is not yet clear. However, the results so far are promising.
Restless Legs Syndrome: typical symptoms
As its name suggests, the main symptom of this condition is to have restless legs. Those people affected by restless legs syndrome feel the urge to move their legs constantly. In addition, unpleasant feelings or sensations such as pulling or tingling in the legs can also occur. Frequently, cramp-like complaints and pain also occur.
Basically, patients experience RLS differently. While for some the urge to move is particularly agonizing, others suffer more from the sensations. In addition, both legs are not always affected at the same time. Thus, the complaints can occur in only one leg or they occur alternating in both legs.
However, it is typical for RLS that the symptoms worsen in sitting and lying down. Movements, on the other hand, provide relief. The following symptoms may also accompany the disease:
- Difficulty falling asleep and sleeping through the night
- Tiredness during the day
- Concentration disorders
Restless Legs Syndrome: What are the causes?
So far, the exact causes have not been clarified. Researchers suspect that the dopamine metabolism in the brain might be disturbed – similar to Parkinson’s disease, which also causes movement disorders. As a result of this disorder, the transmission of nerve signals can be defective. But a disturbance in the brain stem and cerebellum could also be the cause.
An inherited component may also be a possible cause. In the meantime, a gene has been identified that could be involved in the development of the neurological disease. However, the exact connections have not yet been clarified. It is also questionable whether this is the sole cause.
What forms of restless legs syndrome are there?
RLS distinguishes between the following two forms:
- Primary Restless Legs Syndrome (idiopathic form): The causes are not known here.
- Secondary restless legs syndrome: In the secondary form, the disease occurs as a result of other diseases. For example, the diseases diabetes mellitus, polyneuropathy, multiple sclerosis, Parkinson’s syndrome or thyroid dysfunction can trigger RLS. However, vitamin B12 deficiency, folic acid deficiency or iron deficiency can also be the cause.
What medications can cause restless legs syndrome?
It is now known that certain drugs can also trigger or even aggravate the syndrome. This is especially true for drugs that interfere with the brain metabolism. These include, for example, drugs with a mood-lifting effect (antidepressants).
Restless Legs Syndrome: diagnosis and therapy
The diagnosis is based on the typical RLS symptoms:
- The urge to move the legs only manifests itself at rest.
- The urge to move increases in resting phases.
- Sensations such as tingling, pulling or pain in the legs occur.
- The RLS symptoms are more pronounced in the evening or at night.
In addition, a blood test is carried out to rule out possible deficiencies. An extensive neurological examination is also necessary.
To confirm the diagnosis, doctors often carry out a so-called L-Dopa test. If the RLS symptoms improve while taking L-Dopa, this can confirm the diagnosis. If the symptoms do not improve, this does not mean yet that RLS is not present. This is because the connections between RLS and dopamine metabolism have not yet been definitively clarified.
The treatment of restless legs depends on how severe the symptoms are and how much the patient suffers. If it is possible triggering diseases have been excluded, the patient can be prescribed an L-dopa preparation (e.g. levodopa). It is also possible to combine the active substances levodopa and benserazide, as well as drug therapy with dopamine agonists (e.g. ropinirole, pramipexole or rotigotine). Dopamine agonists can imitate the messenger substance dopamine and thus develop a dopamine-like effect.
If it is a very pronounced and painful form of RLS, patients are sometimes prescribed anti-epileptic drugs or strong painkillers (opioids).
What helps against restless legs syndrome?
If the syndrome is mild to moderate, patients can help themselves with various measures. For example, many RLS patients report that foot baths, alternating showers and leg massages can alleviate the symptoms. Stretching exercises and regular sport can also help to alleviate symptoms. Patients should also avoid alcohol, caffeinated drinks and nicotine before going to bed, as these substances can increase the symptoms.
Furthermore, the intake of vitamin B12, folic acid and iron could also have a beneficial effect. However, this should be discussed in advance with the doctor treating you.
Medical cannabis as a therapy option
Clinical studies on the use of medical cannabis in restless legs syndrome are very few and far between. Nevertheless, these few studies are promising. At the Université de Bordeaux in France there was a case study with six RLS patients who used cannabis to relieve the symptoms (1). Five of the patients reported that the symptoms disappeared almost completely after cannabis use. One patient even spoke of complete remission. The patients further explained that the quality of sleep improved significantly under cannabis use.
Interesting is also a study from the Universidad Complutense de Madrid. It is known that cannabinoids from the cannabis plant such as delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD) interact with the cannabinoid receptors (CB1 and CB2 receptors) of the endocannabinoid system. The researchers found indications that this could also regulate dopamine release. This dopamine regulation has already been shown to be effective in the treatment of movement disorders, for example in Parkinson’s disease.
Cannabidiol (CBD) against restless legs
Various studies suggest that the non-psychoactive cannabinoid cannabidiol (CBD) may relieve symptoms such as tremor, anxiety and sleep disturbances. The use of CBD in restless legs syndrome could be considered as a solution to the anxiety and sleep problems (2).
With regard to CBD and movement disorders, the study results are inconclusive. For example, in one study, Parkinson’s patients did not experience symptom relief from CBD therapy (3). The researchers believe that CBD might play less of a therapeutic role, but could be used preventively in Parkinson’s Disease. Further research is needed, however.
The current study data are not yet sufficient to draw conclusions regarding the movement disorders associated with restless legs syndrome. Despite the widespread publicity about the medical benefits of cannabinoids, further pre-clinical and clinical studies are necessary to better characterize the pharmacological and therapeutic effects.
(1) Département de Neurophysiologie Clinique, France, Megelin T1, Ghorayeb I2, 2017, “Cannabis for restless legs syndrome: a report of six patients”
Clinical studies on the use of medical cannabis in restless legs syndrome are very few and far between. Nevertheless, these few studies are promising.