Restless legs syndrome

Restless Legs: When is it Varicose Veins?

"Restless legs" is a common complaint - especially in the evening and at night. For some, it is actually Restless Legs Syndrome (RLS / Willis-Ekbom disease), a neurological condition. For others, the complaint resembles symptoms of chronic venous insufficiency and varicose veins. The two pictures are easily confused and can occur in the same person, without it being established that the veins are the cause.

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Restless Legs Syndrome (RLS)

In the REST survey, which interviewed 15,391 adults in Europe and the United States, 7.2% reported RLS symptoms in the past year, 5.0% had symptoms at least weekly and 2.7% had symptoms at least twice a week with moderate or severe distress, which the authors call clinically significant RLS (Allen RP, et al. Arch Intern Med 2005;165(11):1286-92). The figures depend on the criteria used. The diagnosis is clinical and is only made when all five essential IRLSSG consensus criteria are met [1]:

1. An irresistible urge to move the legs, often accompanied by discomfort
2. Symptoms begin or worsen during rest
3. Symptoms are relieved by movement
4. Symptoms are worse in the evening/at night
5. The symptoms are not solely accounted for by another condition (for example leg cramps, venous insufficiency, oedema or habitual foot tapping)

The mechanisms behind RLS are not fully understood. Both brain iron and dopaminergic signalling are involved, but this is not settled as a single causal chain. Even with a normal serum ferritin, iron stores in the central nervous system can be low [2].

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Venous Symptoms and RLS - Overlap and Confusion

Venous disease can occur alongside RLS and is a relevant differential diagnosis, because heavy, restless legs also occur in chronic venous insufficiency. Visible varicose veins do not show that the veins cause RLS. The literature consists of small, unblinded observational and treatment studies from phlebology clinics, and it cannot settle causation:

Evidence note: A few series from vein clinics have described RLS symptoms as more common among their patients, and some patients reported fewer complaints after venous treatment [3,4,5]. The studies are small, unblinded and based on selected patients, so they can neither show causation nor support an expectation of a particular effect.

Clinical consideration: With visible varicose veins, heavy legs at the end of the day or swelling around the ankles, a venous assessment can be relevant in its own right. It is not a precondition for treating RLS, and the order of investigations and treatment is decided individually with your doctor.

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Assessment

The assessment starts with a clinical medical evaluation covering the history and the five diagnostic criteria.

• Iron status (ferritin and transferrin saturation) is often relevant, because low iron stores can worsen RLS [2]
• Other blood tests are chosen according to the history and findings, not as a fixed panel for everyone
• Medication review, because antihistamines, SSRIs and neuroleptics among others can trigger or worsen symptoms
• Venous investigation, including Doppler ultrasound, only where there is an independent suspicion of venous disease, such as visible varicose veins with venous symptoms, swelling or skin changes. It is not a routine test in RLS [6]

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Treatment

RLS and venous disease are treated separately. Vein treatment is not a treatment for RLS.

RLS:

• Iron treatment when iron stores are low. The indication, route and dose are decided by the doctor based on the blood tests [2]
• A medical review of medicines that can trigger or worsen the symptoms. Never stop or change prescribed medication without agreeing it with your doctor
• Sleep habits. Alcohol and caffeine in the evening worsen symptoms for some people but not for everyone, so this has to be tested individually
• Drug treatment is chosen individually by the doctor. The 2025 American Academy of Sleep Medicine guideline no longer recommends dopamine agonists as a standard first choice for long-term treatment, partly because of augmentation, where symptoms become worse and start earlier in the day. The choice depends on symptoms, iron status, other conditions and other medicines [7]
• Referral for a neurological assessment may be relevant after an individual assessment, for example if symptoms do not improve sufficiently

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If Venous Disease Is Also Documented

If venous reflux with venous symptoms is demonstrated, it can be treated in its own track: graduated compression stockings chosen individually according to symptoms, skin condition and arterial status, and possibly endovenous laser therapy (EVLT). That is treatment of the vein disease, not of RLS [5,6].

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When Should You See a Doctor?

• The symptoms affect your sleep, your mood or your daily function
• The symptoms persist or are getting worse
• You or your doctor suspect another condition behind the complaints
• Visible varicose veins or swelling around the ankles that you would like assessed

Urgent: New swelling in one leg, especially with pain, warmth or redness, does not belong to the picture of restless legs and should be assessed by a doctor the same day. With breathlessness or chest pain, call the emergency number.

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Treatment at Kirurgen.dk

We assess for venous disease with Doppler ultrasound and offer endovenous laser therapy (EVLT) where there is a venous indication. Whether a referral and public cover are possible, and any waiting time, depend on the specific service and the rules in force, and are clarified before treatment. Read also about leg cramps and heavy, tired legs.

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References

1. Allen RP, et al. Restless legs syndrome/Willis-Ekbom disease diagnostic criteria: updated IRLSSG consensus criteria. Sleep Med 2014;15(8):860-73.
2. Allen RP, et al. Evidence-based and consensus clinical practice guidelines for the iron treatment of restless legs syndrome/Willis-Ekbom disease in adults and children. Sleep Med 2018;41:27-44.
3. McDonagh B, King T, Guptan RC. Restless legs syndrome in patients with chronic venous disorders: an untold story. Phlebology 2007;22(4):156-63.
4. Hayes CA, Kingsley JR, Hamby KR, Carlow J. The effect of endovenous laser ablation on restless legs syndrome. Phlebology 2008;23(3):112-7.
5. de Carvalho MR, et al. Endovenous laser ablation in patients with restless legs syndrome and lower-limb venous insufficiency. J Vasc Surg Venous Lymphat Disord 2020;8(5):820-6.
6. Gloviczki P, Lawrence PF, Wasan SM, et al. The 2022 SVS/AVF/AVLS clinical practice guidelines for the management of varicose veins of the lower extremities. Part I. Duplex scanning and treatment of superficial truncal reflux. J Vasc Surg Venous Lymphat Disord 2023;11(2):231-261.e6. DOI: 10.1016/j.jvsv.2022.09.004. PubMed
7. Winkelman JW, Berkowski JA, DelRosso LM, et al. Treatment of restless legs syndrome and periodic limb movement disorder: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med 2025;21(1):137-152. DOI: 10.5664/jcsm.11390. PubMed