What is the best treatment for nocturnal (night-time) cramps?

Treatment of Nocturnal Leg Cramps

The best treatment for nocturnal leg cramps is a combination of daily calf and hamstring stretching exercises, which should be performed for at least 6 weeks, as this is the only non-pharmacological intervention with evidence for reducing cramp severity. 1

First-Line Treatment: Stretching Protocol

• Perform daily calf and hamstring stretching exercises before bedtime for a minimum of 6 weeks, as this may reduce cramp severity by approximately 1.3 points on a 10-point pain scale in adults over 55 years 1
• The stretching should target both muscle groups, not just the calves alone, since calf stretching by itself shows little to no benefit on cramp frequency 1
• Acute cramp episodes should be managed with immediate massage and stretching of the affected muscle 2

Medication Review (Critical Step)

Before considering any pharmacological treatment, systematically review and adjust medications that commonly trigger nocturnal cramps:

• Diuretics are strongly associated with leg cramps and should be taken in the morning rather than evening, or dosing should be reduced if medically appropriate 3, 4
• Long-acting beta-agonists predispose to leg cramps and alternatives should be considered 3
• Other high-risk medications include intravenous iron sucrose, conjugated estrogens, raloxifene, naproxen, and teriparatide 4

Pharmacological Treatment (Reserved for Severe Cases Only)

Quinine sulfate is the only medication proven to reduce cramp frequency and intensity, but should be restricted to patients with severe, disabling symptoms due to significant safety concerns. 3, 4

Quinine Use Guidelines:

• The benefit is modest at best, reducing cramp frequency but not eliminating cramps entirely 3
• Serious risks include rare but potentially fatal immune-mediated reactions (thrombocytopenia, hemolytic uremic syndrome) 3
• Dose-related side effects are particularly problematic in older adults, including cinchonism (tinnitus, hearing loss, visual disturbances) 3
• Quinine is no longer recommended as routine treatment by most guidelines 4
• If used, treatment requires explicit discussion of risks versus benefits with the patient and mandatory regular review to reassess necessity 3

Alternative Medications (Limited Evidence):

• Magnesium, calcium channel blockers, carisoprodol, and vitamin B12 have limited supporting evidence 4
• These options may be considered when stretching fails and quinine is contraindicated, but expectations should be modest 4

Diagnostic Workup

Perform targeted evaluation to identify secondary causes:

• History should focus on: vascular disease symptoms, lumbar canal stenosis (neurogenic claudication pattern), cirrhosis, hemodialysis status, and complete medication list 4
• Physical examination should assess: peripheral pulses, neurological function (to exclude peripheral neuropathy), and signs of lumbar stenosis 4
• Laboratory testing is usually unnecessary unless history suggests specific metabolic abnormalities 4
• Distinguish from restless legs syndrome (urge to move legs, relieved by movement, worse at rest), claudication (exercise-induced, relieved by rest), and myositis (persistent muscle pain) 4

Common Pitfalls to Avoid

• Do not assume electrolyte abnormalities are the cause - cramps are more likely due to muscle fatigue and nerve dysfunction rather than electrolyte imbalances 4
• Avoid prescribing quinine as first-line therapy without attempting conservative measures first 3, 4
• Do not continue quinine indefinitely without regular reassessment of benefit versus risk 3
• Recognize that many patients use diverse, unproven treatments (17 different drug treatments and 13 non-drug treatments reported in one study), many of which may be harmful 5

Treatment Algorithm Summary

1. Initiate daily calf and hamstring stretching exercises for 6 weeks minimum 1
2. Review and optimize all medications, particularly diuretics and beta-agonists 3, 4
3. Evaluate for secondary causes through focused history and examination 4
4. Reserve quinine for severe, refractory cases only after thorough risk-benefit discussion 3, 4
5. Provide acute management education: immediate stretching and massage during cramp episodes 2

The evidence base for nocturnal leg cramps remains limited, with most treatments showing inconsistent results due to unvalidated outcome measures and varying diagnostic criteria 1. However, the stretching protocol and medication review represent the safest, evidence-based approach with the most favorable risk-benefit profile for this common and disabling condition affecting up to 60% of older adults 4.