What are the recommended treatments for leg spasms?

Recommended Treatments for Leg Spasms

For leg spasms, alpha-2-delta ligands such as gabapentin, gabapentin enacarbil, or pregabalin are recommended as first-line pharmacological treatment due to their efficacy and lower risk of adverse effects. 1

Diagnosis and Classification

• Leg spasms may be classified as true cramps, contractures, tetany, or dystonias, with idiopathic cramps being the most common type 2
• Distinguish leg spasms from other conditions such as restless legs syndrome (RLS), which is characterized by an uncomfortable urge to move the legs that worsens at rest and in the evening 3, 4
• For RLS diagnosis, look for four key symptoms: uncomfortable sensations with urge to move legs, symptoms worsening during rest/inactivity, relief with movement, and symptoms worsening in evening/night 3

Non-Pharmacological Treatments

First-Line Non-Pharmacological Options:

• Stretching exercises are recommended as first-line treatment for leg spasms, particularly daily calf and hamstring stretching 5
• Massage of the affected muscle can provide immediate relief for acute leg cramps 6
• Walking or movement of the affected limb during an acute cramp can help relieve symptoms 6
• Relaxation techniques to reduce muscle tension and cocontraction 3

Additional Non-Pharmacological Approaches:

• Compression devices may help reduce symptoms, particularly for RLS-related leg discomfort 7
• Avoid postures that promote prolonged positioning of joints at the end of range (e.g., full hip, knee or ankle flexion while sitting) 3
• Encourage even distribution of weight in sitting, transfers, standing and walking to normalize movement patterns 3
• Consider bilateral high-frequency peroneal nerve stimulation for RLS-related leg discomfort 4

Pharmacological Treatments

First-Line Pharmacological Options:

• Alpha-2-delta ligands (gabapentin, gabapentin enacarbil, or pregabalin) are strongly recommended as first-line therapy for leg spasms, particularly those related to RLS 4, 1
• For acute, painful musculoskeletal conditions with associated muscle spasm, cyclobenzaprine can be used as an adjunct to rest and physical therapy for short periods (up to 2-3 weeks) 8

Second-Line Pharmacological Options:

• Tizanidine can be considered for chronic muscle spasticity, particularly in patients with spasticity following stroke 1
• Baclofen may be used for spasticity resulting in pain, poor skin hygiene, or decreased function 1
• Extended-release oxycodone and other low-dose opioids may be considered for moderate to severe cases, particularly for refractory cases 4

Iron Supplementation:

• Check serum iron studies, including ferritin and transferrin saturation, in patients with RLS-related leg spasms 4
• Consider iron supplementation if serum ferritin ≤75 ng/mL or transferrin saturation <20% 4

Special Considerations

Medications to Avoid:

• Diazepam and other benzodiazepines should be avoided during stroke recovery due to possible negative effects on recovery 1
• Dopaminergic agents (levodopa, pramipexole, ropinirole, rotigotine) should be avoided for long-term use due to risk of augmentation 4, 1
• Caution with antipsychotics that block dopamine receptors as they may worsen RLS symptoms 4

Monitoring and Management:

• If using dopaminergic agents for RLS-related leg spasms, monitor for augmentation (worsening and earlier onset of symptoms) 3, 9
• For patients with end-stage renal disease and leg spasms, gabapentin is suggested as an effective treatment option 1

Treatment Algorithm

1. Start with non-pharmacological approaches:

   • Daily stretching exercises (calf and hamstring) 5
   • Massage and movement during acute cramps 6
   • Proper posture and weight distribution 3

2. If non-pharmacological approaches are insufficient:

   • Check iron status if RLS is suspected and supplement if needed 4
   • Start with alpha-2-delta ligands (gabapentin, pregabalin) as first-line pharmacological therapy 1
   • Consider cyclobenzaprine for short-term use in acute musculoskeletal conditions 8

3. For refractory cases:

   • Consider second-line agents like tizanidine or baclofen 1
   • Extended-release opioids may be considered for severe cases 4

Common Pitfalls and Caveats

• Cyclobenzaprine should only be used for short periods (up to 2-3 weeks) as evidence for longer use is not available 8
• Cyclobenzaprine is not effective for spasticity associated with cerebral or spinal cord disease 8
• Dopaminergic agents may provide short-term relief but can lead to augmentation with long-term use 4, 9
• Many patients use over-the-counter analgesics for leg cramps, which could potentially lead to adverse events with long-term use 6
• Nearly one-third of patients with leg cramps search for treatments on the internet, potentially leading to use of unproven remedies 6