Can Valium (diazepam) contribute to worsening Restless Legs Syndrome (RLS) symptoms in patients, particularly those with a history of neurological or sleep disorders?

Can Valium Worsen Restless Legs Syndrome Symptoms?

No, benzodiazepines like Valium (diazepam) do not directly worsen RLS symptoms and are not listed among medications that exacerbate RLS, though they are no longer recommended as primary treatment due to lack of efficacy evidence and potential side effects. 1

Medications That Actually Worsen RLS

The evidence clearly identifies specific drug classes that exacerbate RLS symptoms, and benzodiazepines are notably absent from this list:

• Antidopaminergic medications (antipsychotics like olanzapine and lurasidone) are well-established RLS triggers through dopamine receptor blockade 1, 2
• Serotonergic antidepressants including SSRIs, tricyclic antidepressants, mirtazapine, and mianserin can worsen symptoms 1, 3
• Antihistaminergic medications are specifically mentioned as exacerbating factors 1
• Lithium has been reported to worsen RLS 1

Current Role of Benzodiazepines in RLS Treatment

While benzodiazepines don't worsen RLS, their therapeutic role has significantly diminished:

• The American Academy of Sleep Medicine explicitly recommends against clonazepam (the most studied benzodiazepine for RLS) as standard treatment, with a conditional recommendation and very low certainty of evidence 1
• A 2017 Cochrane systematic review found zero randomized controlled trials meeting inclusion criteria for benzodiazepine efficacy in RLS 4
• Benzodiazepines primarily improve subjective sleep quality but do not reduce periodic limb movement index, the objective disease marker 1

When Benzodiazepines May Be Temporarily Used

There is one specific clinical scenario where benzodiazepines have documented utility:

• During dopamine agonist withdrawal when transitioning to first-line alpha-2-delta ligands, clonazepam can be temporarily introduced to manage the severe rebound of RLS and insomnia symptoms that occur during ropinirole or pramipexole tapering 3
• This is a bridge therapy only, not ongoing treatment 3

Important Caveats About Valium Specifically

While not an RLS-worsening agent, Valium carries risks relevant to RLS patients:

• Sedation, drowsiness, and ataxia are common side effects that may compound the sleep disruption and daytime fatigue already present in RLS 5
• Falls and fractures are reported in benzodiazepine users, with increased risk in elderly patients—a concern since RLS prevalence increases with age 5
• Paradoxical reactions including restlessness, agitation, and sleep disturbances can occur, which could be confused with worsening RLS 5

Evidence-Based Treatment Algorithm

If a patient with RLS is taking Valium and experiencing worsening symptoms, the priority should be:

1. Assess iron status first: Check morning fasting ferritin and transferrin saturation; supplement if ferritin ≤75 ng/mL or transferrin saturation <20% 1
2. Review other medications for true RLS-exacerbating agents (antidepressants, antipsychotics, antihistamines) 1
3. Initiate first-line treatment with alpha-2-delta ligands (gabapentin, gabapentin enacarbil, or pregabalin) rather than continuing benzodiazepines 1
4. Address modifiable factors including caffeine, alcohol, and untreated obstructive sleep apnea 1

Bottom Line for Clinical Practice

Valium is not causing the RLS worsening, but it's also not effectively treating it. The symptom progression is likely due to the natural course of RLS, inadequate treatment, or concurrent use of actual RLS-worsening medications. The solution is to transition to evidence-based first-line therapy with alpha-2-delta ligands after optimizing iron status, not to discontinue the benzodiazepine based on concerns about RLS exacerbation 1.