Which Specialist Treats Restless Leg Syndrome
Primary care physicians can and should diagnose and manage most cases of Restless Legs Syndrome (RLS), with referral to a sleep medicine specialist or neurologist reserved for refractory cases, severe symptoms not responding to first-line therapy, or diagnostic uncertainty. 1, 2
Initial Management in Primary Care
Most RLS patients can be effectively managed in the primary care setting using a straightforward algorithmic approach 3:
- Check morning fasting iron studies (ferritin and transferrin saturation) in all patients with clinically significant RLS, avoiding iron supplements for at least 24 hours before testing 1, 2
- Initiate iron supplementation if ferritin ≤75 ng/mL or transferrin saturation <20%, which differs from general population guidelines and is specific to RLS management 1, 2
- Start first-line pharmacological therapy with alpha-2-delta ligands (gabapentin, gabapentin enacarbil, or pregabalin) for patients requiring medication 1, 2
- Address exacerbating factors including alcohol, caffeine, antihistamines, antidepressants (SSRIs), antipsychotics, and untreated obstructive sleep apnea 1, 2
When to Refer to a Specialist
Refer to a sleep medicine specialist or neurologist in the following situations 3:
- Diagnostic uncertainty or atypical presentation requiring differentiation from RLS mimics (neuropathy, akathisia, positional discomfort, nocturnal leg cramps) 1
- Failure to respond to first-line alpha-2-delta ligands at adequate doses 4, 5
- Development of augmentation (paradoxical worsening with earlier symptom onset, increased intensity, or anatomic spread) 4, 5
- Severe refractory symptoms requiring consideration of opioid therapy, which needs specialized monitoring 4, 5
- Complex cases involving pregnancy, end-stage renal disease, or multiple comorbidities 1
- Need for IV iron formulations (ferric carboxymaltose) when oral supplementation fails 1, 2
Common Pitfall to Avoid
Do not refer immediately without first attempting the basic algorithmic approach outlined above, as approximately two-thirds of patients achieve acceptable symptom relief with initial treatments managed in primary care 4. The key is recognizing that RLS remains largely underdiagnosed in primary care despite being highly treatable 3, so the focus should be on improving primary care recognition and management rather than reflexive referral.
Sleep medicine specialists have particular expertise in managing the one-third of patients who don't respond to initial therapy and in navigating complex medication switches, particularly when transitioning patients off dopamine agonists that have caused augmentation 4, 5.