What is the current treatment for restless legs syndrome?

Guidance changed substantially in 2025. The American Academy of Sleep Medicine now recommends against routine use of the dopamine agonists that were standard for years, including pramipexole and ropinirole, because of augmentation, where the drug gradually makes symptoms worse. Current guidance favors an iron-focused approach plus gabapentin enacarbil, gabapentin or pregabalin (AASM clinical practice guideline, 2025).

Restless Legs at Night: Why It Gets Worse in Perimenopause

Q: How do I know if it's really restless legs syndrome?

Five features define it: an urge to move the legs, usually with an uncomfortable sensation; it starts or worsens at rest; movement relieves it, at least partly; it's worse in the evening or at night; and it isn't better explained by something else such as cramps or positional discomfort. The relief from movement is the feature that separates it from an ache, which movement does little for.

By Alison Quillen · Published September 1, 2026 · Last reviewed September 22, 2026

Restless legs syndrome is defined by an urge to move your legs that movement genuinely relieves, and that returns the moment you stop. It worsens for many women around perimenopause, partly because estrogen declines and partly because dopamine hits its daily low overnight. The 2025 treatment guidance changed significantly.

Bare feet resting on a rumpled white bed sheet. — Photo: Brooke Balentine / Unsplash

This one isn't really about waking up. It's about not being able to stay still once you're lying down, and then losing an hour to walking up and down the hall at 3am because it's the only thing that works.

Before anything else, it's worth checking that this is what you actually have. Restless legs syndrome is over-diagnosed in casual conversation and under-diagnosed in clinics, which is a strange combination. Plenty of women who describe their legs as "restless" at night turn out to have a deep muscular ache or a cramp, and some are actually describing an itch with nothing to see on the skin, not an urge to move at all. None of the three respond to the treatments below.

How do I know if it's really restless legs syndrome?

There are five agreed features, and all five have to be present:

An urge to move the legs, usually alongside an uncomfortable sensation described as crawling, pulling, fizzing or creeping
It starts or gets worse during rest or inactivity
Moving relieves it, at least partly, for as long as you keep moving
It's worse in the evening and at night than during the day
It isn't better explained by something else, such as cramps, positional discomfort or habitual foot tapping

The third one is the test that matters most. With restless legs, standing up and walking gives immediate relief, and the sensation comes back within a minute of settling again. If your legs hurt in a dull, heavy way and walking around changes nothing, that's a different problem with different answers, and it's much more likely to be the joint and muscle pain that rises across the menopause transition.

That fifth criterion exists precisely because so many things imitate this one. It's in the official definition for a reason.

Why does it get worse around perimenopause?

A survey of a random sample of 5,000 Swedish women aged 18 to 64 found that 15.7% reported restless legs syndrome, with prevalence rising with age, and women with RLS more often reported disrupted sleep and depressed mood alongside it (Wesström et al., Climacteric, 2008).

Two things are probably happening at once. Estrogen appears to have a calming, protective effect on the nervous system, and as it declines that buffer thins. Iron status matters at least as much, because RLS is strongly tied to iron stores in the brain, and women with heavy perimenopausal bleeding are exactly the group most likely to be running low without knowing it.

Why does it hit hardest around 3am?

Restless legs is closely tied to dopamine signaling, and dopamine runs on a daily rhythm of its own. An early but still frequently cited study measuring plasma dopamine through the night in nine men found levels were lowest during sleep, in the early morning hours, and tracked more closely to clock time than related hormones like norepinephrine (Sowers & Vlachakis, Journal of Endocrinological Investigation, 1984). Small study, and an old one, but the broad pattern has held up since.

A condition that's partly a dopamine shortage shows up hardest when dopamine is at its lowest. That lines up uncomfortably well with the hour this site is named after.

Illustrative, based on the general pattern described in Sowers & Vlachakis, 1984, not a precision measurement.

What is the current treatment, and why did it change?

This part is worth reading even if you were diagnosed years ago, because the standard advice was reversed recently and plenty of information online still reflects the old version.

For years the first-line drugs were dopamine agonists, pramipexole and ropinirole in particular. In 2025 the American Academy of Sleep Medicine issued updated guidance recommending against their routine use, along with rotigotine and levodopa, because of augmentation: the drug works at first, then over months or years the symptoms get earlier in the day, more intense and spread to other parts of the body. The current recommendations favor gabapentin enacarbil, gabapentin or pregabalin instead, alongside an iron-focused approach (AASM clinical practice guideline, Journal of Clinical Sleep Medicine, 2025).

On iron, the threshold that gets used is higher than the one for ordinary anemia, which is why "your iron is fine" can be true and unhelpful at the same time. Guidance supports iron treatment when serum ferritin is at or below 75 µg/L, or when transferrin saturation is under 20%, and intravenous iron is considered when ferritin sits between 75 and 100. Ask for the actual ferritin number rather than accepting "normal," because normal for general health and low for restless legs overlap.

What actually helps?

Moving does, in the moment. Walking or stretching genuinely relieves symptoms while you're doing it, which is diagnostic as much as therapeutic.

Getting ferritin checked is the single most useful thing on this list, because correcting a real deficiency can meaningfully improve symptoms and it's an ordinary blood test rather than a guess.

Beyond that, the honest answer is that home remedies here have thin evidence and a doctor's involvement matters more than usual. This is a condition tied to a specific neurotransmitter system with a documented history of treatments that backfire over time, which is not a good place to improvise with supplements. If you're currently on a dopamine agonist and your symptoms have been creeping earlier into the evening, that's augmentation, and it's a conversation to have rather than something to push through.

When to see a doctor

Raise this directly rather than in passing, since restless legs is frequently missed unless specifically asked about. Ask for an iron panel including ferritin, and ask for the number. If you're already on treatment and symptoms are appearing earlier in the day than they used to, say so explicitly, because that's the pattern that signals augmentation and it changes the plan. If the sensations are in one leg only, come with numbness or weakness, or follow a back injury, that points toward a nerve or circulation problem instead and deserves its own assessment.

Sources

Wesström J, Nilsson S, Sundström-Poromaa I, et al. "Restless Legs Syndrome Among Women: Prevalence, Co-morbidity and Possible Relationship to Menopause." Climacteric, 2008. Abstract.
"Treatment of Restless Legs Syndrome and Periodic Limb Movement Disorder: An American Academy of Sleep Medicine Clinical Practice Guideline," 2025. Abstract.
Sowers JR, Vlachakis N. "Circadian Variation in Plasma Dopamine Levels in Man." Journal of Endocrinological Investigation, 1984. Abstract.

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