Restless Legs Syndrome (RLS), also known as Willis-Ekbom Disease, can be dismissed as nothing more than a nighttime nuisance. Many people assume it’s just a harmless twitch or an odd discomfort that makes it hard to fall asleep.
But research shows there’s more to the story. RLS is a neurological condition that affects the whole body, influencing both cardiovascular and brain health. It can disrupt sleep patterns, alter key brain chemicals, and place added strain on the heart and blood vessels.
Those uneasy nighttime sensations are more than an annoyance. They’re a signal that your body may be under broader stress.
Iron, Dopamine, Genetics, and Restless Legs
Restless legs disrupt the brain’s chemistry in unexpected ways. Even when iron levels in the blood are normal, iron inside the brain can run low. Doctors refer to this as the “iron paradox.”
Standard blood tests might look fine, yet the brain isn’t getting what it needs. This often happens when the blood-brain barrier fails to let enough iron through.
In some cases, an excess of a protein called hepcidin further limits iron delivery. Without enough iron, nerve cells struggle to function properly, and their mitochondria can become less efficient, setting off a chain of neurological effects.
Iron plays many roles in the body, but in RLS, it’s especially important for making dopamine. Low brain iron affects a key enzyme in dopamine production, throwing off this signaling system, particularly in areas that control movement. Dopamine neurons act as a communication hub between the brain and spinal cord, helping to keep reflex activity balanced.
When dopamine levels drop or fluctuate, that balance is lost. The spinal cord becomes flooded with “go” signals driven by another chemical messenger, glutamate. The result is the uncomfortable, restless energy people with RLS often describe.
It’s not just motor restlessness, but a sensory overload that the body tries to relieve by moving.
“Peripheral iron deficiency is known to be a contributing factor to both the worsening of the symptoms as well as a cause of the disease,” according to PubMed Central and the National Library of Medicine. “Several studies have found a strong negative correlation between peripheral iron stores as determined by serum ferritin and RLS severity: decreasing ferritin was associated with increasing RLS severity. In support of a causal relationship between peripheral ID and RLS, there have been several studies in which the prevalence of RLS is substantially greater in patients with IDA (35-45%).”
Genetics also play a strong role. Dozens of genetic variants appear more often in people with RLS, many passed through families. These genes affect both limb development and how the body regulates iron, which may explain why RLS tends to run in families.
Some of the same genetic patterns are also linked with blood pressure that stays elevated at night, adding another layer to the connection between RLS and the body’s overall physiology.
Physiological Toll of Periodic Leg Movements
The real strain on the heart usually begins once a person with restless legs falls asleep. Most people with RLS experience rhythmic leg movements during the night—brief muscle jerks that can occur every 20 to 40 seconds. They rarely wake up fully, but these movements repeatedly disturb deep sleep. Brain wave studies show these as bursts of activity on EEGs, indicating that the brain is being partially aroused again and again.
Research has uncovered something even more striking: blood pressure and heart rate rise before the legs move. It’s as if the brain triggers a stress response before the muscles react. The nervous system essentially whips the cardiovascular system into action over and over throughout the night.
Each leg movement can spike blood pressure by 20 to 30 points. For someone whose legs kick dozens of times an hour, that’s hundreds of small blood pressure surges every night—thousands each week. Instead of the expected nighttime “rest period,” their heart is repeatedly pushed as if undergoing stress tests.
Normally, blood pressure drops by about 10–20% during sleep, giving the heart and blood vessels a chance to recover. People with frequent leg movements often miss out on this dip. Their blood pressure stays elevated or even climbs, putting steady strain on the cardiovascular system. Over time, this constant pressure thickens artery walls, enlarges the heart muscle, and damages the lining of blood vessels, making them less flexible.
These changes build quietly but have real consequences. Left untreated, they raise the risk of chronic hypertension, heart failure, and stroke. What may start as an irritating nighttime condition can gradually become a serious threat to cardiovascular health.
“Mounting evidence has shown that frequent sleep disturbances may predispose some people to heart conditions,” according to the American College of Cardiology. “New data demonstrates that people with Restless Legs Syndrome (RLS) – characterized by frequent and involuntary leg movement during sleep – have more thickening of their heart muscle, known as left ventricular hypertrophy (LVH), and those with severe LVH have more than two-fold risk of having any cardiac event or death.”
The Sleep-Heart Connection: Insomnia as a Stressor
The heart problems linked to restless legs extend far beyond the muscle twitches themselves. Chronic sleep loss and ongoing discomfort add to the burden.
Imagine someone lying awake, their legs firing with strange sensations and sudden jolts. Their body interprets this as stress. Hormones like cortisol and norepinephrine rise and stay high.
Over time, those stress hormones take a toll, damaging blood vessels, promoting inflammation, and encouraging fat buildup around the abdomen. Together, these changes set the stage for high blood pressure, diabetes, and atherosclerosis.
Sleep disturbances rarely occur in isolation. Many people with RLS also experience Obstructive Sleep Apnea (OSA), a combination that’s especially hard on the heart. Someone may wake gasping from an apnea event, heart pounding, only to be hit moments later by the urge to move their legs. The body stays on alert, unable to reach the deep, restorative stages of sleep.
On particularly bad nights, oxygen levels can drop sharply, and heart rhythms can become erratic. This can lead to atrial fibrillation or more serious cardiac events.
Treating RLS is about more than comfort. Effective therapy helps quiet the body’s stress response, improves sleep quality, and reduces cardiovascular strain. When symptoms are under control, the heart and nervous system finally get the chance to rest and recover.
A Comparative View of Sleep Health
Looking at how untreated restless legs affects the body makes the picture clear. In healthy sleep, heart rate and blood pressure stay steady and gradually fall as the body rests.
For someone with RLS, it’s a different story. Their sleep is filled with sudden surges — brief spikes in heart rate and blood pressure that break the normal rhythm of the night. The usual nocturnal dip in blood pressure disappears, leaving the heart working harder than it should.
Over time, what should be quiet, restorative sleep turns into a series of stress cycles. When you track these numbers side by side, the pattern stands out: repeated bursts of activity, disrupted rest, and constant physiological strain.
| Healthy Sleep Profile | RLS/PLM Sleep Profile | Cardiovascular Consequence | |
| Blood Pressure Pattern | 10–20% Nocturnal Dip | Non-dipping or Riser | Chronic hypertension and arterial stiffness |
| Heart Rate Variability | High (Parasympathetic dominance) | Low (Sympathetic dominance) | Increased risk of Arrhythmias (Afib) |
| Cortisol Levels | Low (Circadian nadir) | Elevated (HPA axis activation) | Systemic inflammation and weight gain |
| Vascular Tone | Vasodilation (Restorative) | Vasoconstriction (Spiking) | Endothelial dysfunction and wall thickening |
| Micro-Arousal Frequency | Less than 5 per hour | 30 to 60-plus per hour | Fragmented sleep and cognitive decline |
Someone with Restless Legs Syndrome (RLS) isn’t simply restless at night. Their body stays in a state of heightened alert.
Strangely, their blood pressure can rise more during sleep than during the day, a reverse pattern that signals increased cardiovascular risk. This nighttime surge is linked to a greater chance of stroke and sudden heart events.
For these patients, the bedroom stops being a place of recovery and becomes a source of strain for the heart. The evidence makes one thing clear: treatment must go beyond easing leg discomfort. Lasting improvement means calming the entire nervous system, not just managing the visible symptoms.
The prevalence of PLMS (Periodic Limb Movements of Sleep) is 4-11 percent in the general population with an age-associated increase up to 25-58 percent in the elderly population, according to Practical Neurology. In fact, PLMS is present in 80 percent of patients with RLS.
“PLMS may also occur in children, with prevalence rates from 3.9 percent to 50 percent, although the coexistence of other medical conditions like sleep apnea, attention-deficit hyperactivity syndrome, migraine, seizures, narcolepsy and other neuropsychiatric conditions may raise the rate,” the neurological publication states. “The highest prevalence of PLMS was 85 percent, reported in a community-based study of elderly patients with a mean age of 67 years. The latter finding underscores the controversy about the clinical relevance of the PLMS. Some authors contend that PLMs are associated with adverse consequences for health, whereas others do not.”
The Case for Multidisciplinary Care
Restless legs often slips through the cracks, especially when heart concerns are the main focus. Specialists tend to stay within their lanes. A cardiologist might struggle to control a patient’s high blood pressure but never think to ask about leg sensations at night.
Meanwhile, a neurologist might treat the leg movements without checking for underlying cardiovascular stress. This kind of tunnel vision hides how closely the heart and brain interact. The result is that many people receive more medications instead of identifying the shared cause behind their symptoms.
A small shift in how clinicians screen patients could make a big difference. Cardiologists should use the URGE tool, asking whether patients feel an urge to move, if rest makes symptoms worse, whether getting up or moving helps, and if symptoms flare up in the evening or at night. For sleep specialists, it’s not enough to look for apnea alone. During sleep studies, they should examine how blood pressure and heart rate fluctuate with each leg movement.
Blood work matters too. Every patient diagnosed with RLS deserves a complete iron panel — not just a standard anemia screen, but detailed tests like transferrin saturation (TSAT) and ferritin. Many experts aim for a ferritin level above a certain level to support proper brain and nerve function.
When cardiology and sleep medicine teams collaborate, the results can be dramatic. Some patients improve significantly with IV iron therapy: their restless legs ease, nighttime blood pressure stabilizes, and medication needs drop.
Treating RLS effectively isn’t only about relief. It’s an important step toward protecting long-term heart health.
Restless Legs Q&A
Here’s a look at questions that pop up the most:
- Can I have RLS even if my doctor says my blood iron levels are normal? Yes. This is sometimes called the iron paradox. Standard blood tests measure total body iron (typically ferritin), but RLS is linked to low iron inside the brain. It’s possible to have normal blood levels while the brain remains deficient. This often happens when the blood-brain barrier doesn’t allow enough iron through. Most RLS specialists aim for a ferritin level that’s high enough, which is higher than what’s considered normal for general anemia screening.
- Why do my symptoms get worse in the evening and at night? The worsening at night follows your body’s natural dopamine rhythm. Dopamine levels naturally decline in the evening, reaching their lowest point overnight. In someone whose dopamine system is already under strain from low brain iron or genetic factors, this normal drop pushes signaling past a threshold — triggering the sensations and the strong urge to move just when you’re trying to rest.
- Does RLS directly cause heart attacks? Not directly, but it significantly raises cardiovascular risk. RLS increases nighttime blood pressure, heart rate, and overall stress on the heart. Over time, that constant strain contributes to high blood pressure, heart failure, and coronary artery disease. It’s not usually the single cause of a heart attack, but it amplifies the long-term wear and tear that leads to one.
- If I treat my RLS, will my high blood pressure go away? In some cases, yes, at least partially. Treating RLS, especially with iron therapy or medications that calm the autonomic nervous system, can reduce nighttime blood pressure spikes. Even if it doesn’t remove the need for medication, it often makes hypertension easier to control and helps restore the nocturnal dip that protects your heart and arteries while you sleep.
- What is the URGE acronym I should share with my doctor? The URGE criteria are the core diagnostic questions for RLS. U: Urge to move the legs, usually with unpleasant sensations. R: Rest makes symptoms worse. G: Getting up or moving brings relief. E: Evening or nighttime is when symptoms peak. Bringing this checklist to your cardiologist or primary care provider can help them see how RLS might be contributing to other health issues, including blood pressure problems.
- Are dopamine medications the only option for RLS? Not anymore. While dopamine agonists were once the standard, many specialists now prefer alpha‑2‑delta ligands such as gabapentin or pregabalin. These drugs often improve sleep and have a lower risk of augmentation (a worsening of symptoms over time). Intravenous iron therapy is also becoming a first‑line option, targeting the core problem — low brain iron — directly and sometimes offering lasting relief without daily medication.
- How is RLS different from leg cramps? Leg cramps are sudden, painful muscle contractions that make the muscle feel tight or hard. RLS, on the other hand, is a neurological condition marked by an urge to move. The sensations, which are described as crawling, tingling or internal restlessness, ease only when you move voluntarily. If the feeling improves when you shift or stretch your legs, it’s more likely RLS than a cramp.
Restless Legs Syndrome (RLS) is more than a sleep issue. It can put real stress on the heart. Low iron levels in the brain and repeated leg movements during the night both add to the strain. The body’s stress response also remains active when it should be resting, compounding the problem.
These signs deserve attention from both patients and doctors. Treating RLS isn’t only about getting better sleep; it also helps safeguard long-term heart health.
Wellness and Pain
Find comfort for your restless legs by visiting Wellness and Pain. We offer conservative treatments, routine visits, and minimally invasive quick-recovery procedures. We can keep you free of problems by providing lifestyle education and home care advice.
This enables you to avoid and manage issues, quickly relieving your inhibiting lifestyle conditions when complications arise. We personalize patient care plans based on each patient’s condition and unique circumstances. Wellness and Pain can help improve wellness, increase mobility, relieve pain, and enhance your mental space and overall health.
