Iron replacement comes first where ferritin is low, since that treats a cause rather than a symptom. Where medication is needed, alpha-2-delta ligands such as gabapentin enacarbil and pregabalin are now generally preferred over dopamine agonists. Dopamine agonists carry a risk of augmentation, a medication-driven worsening that is difficult to reverse, which is why they are no longer generally first choice.
Iron replacement comes first where ferritin is low, since that treats a cause rather than a symptom. Where medication is needed, alpha-2-delta ligands such as gabapentin enacarbil and pregabalin are now generally preferred over dopamine agonists. Dopamine agonists carry a risk of augmentation, a medication-driven worsening that is difficult to reverse, which is why they are no longer generally first choice.
Ferritin should be measured in everyone with restless legs syndrome, and the threshold used here is higher than the usual cutoff for anaemia, so a ferritin reported as normal may still warrant treatment. Correcting low iron can substantially improve or resolve symptoms, which makes it the first step rather than an afterthought. It treats a cause rather than masking a symptom, and it is frequently skipped in favour of going straight to medication.
Dopamine agonists such as pramipexole and ropinirole were long used first-line and work well initially. The problem is augmentation: over months or years symptoms can worsen, start earlier in the day and spread to other body parts, driven by the medication itself. Because augmentation is difficult to reverse, current guidance generally favours starting with alpha-2-delta ligands such as gabapentin enacarbil, gabapentin or pregabalin instead. Dopamine agonists also carry impulse control risks.
Alpha-2-delta ligands cause drowsiness, unsteadiness and sometimes weight gain, and need dose adjustment in kidney impairment. Review medications that aggravate restless legs: many antidepressants, antihistamines and anti-nausea drugs do, and some over-the-counter sleep aids and cold remedies contain antihistamines that worsen it considerably. If symptoms are worsening on a dopamine agonist, report it rather than increasing the dose, since that is the pattern of augmentation.
Clinical Neurology Specialists has been physician-owned since 1998, when Leo Germin, M.D., FAANEM founded it. Five board-certified neurologists and four advanced practice providers see patients at the Las Vegas and Henderson offices, each with its own AANEM-accredited electrodiagnostic laboratory.
Clinical Neurology Specialists is an adult outpatient neurology practice for patients 18 and older. The practice performs no surgery and operates no imaging suite, infusion suite or interventional pain programme, and provides no emergency or inpatient care.
Physician-reviewed. Reviewed by the physicians of Clinical Neurology Specialists — board-certified neurologists, AANEM-accredited electrodiagnostic laboratories, physician-owned since 1998. Reviewed 1 August 2026. This article is general education for adults 18 and older and is not a substitute for a consultation.
Sources and further reading: National Institute of Neurological Disorders and Stroke; MedlinePlus, National Library of Medicine; MedlinePlus: peripheral nerve disorders.
Adults 18 and older, at the Las Vegas and Henderson offices. Call 702-804-1212 or request an appointment online.