Overcoming nocturnal leg cramps

Nocturnal leg cramps are common among elderly patients.
Nocturnal leg cramps are common among elderly patients.

 This week I have had three patients who have complained of terrible nocturnal leg cramps. Well, to be fair, one was my father, so I can't really count him. However, it made me realize that I hear this complaint quite frequently and don't see many articles written on the subject. One of the major sleep textbooks has only one paragraph about nocturnal leg cramps. Needless to say, we need to have more research in this area, as it is a common complaint probably seen more in primary care than by any other specialty.

Leg cramps typically occur in the calves or in the feet, although I have also heard my patients complain of thigh cramps. The cramping may be so severe that it wakes patients from their sleep and can last from seconds to minutes. Some patients complain of nightly cramping while others may only experience cramping occasionally. Some say they have cramps during the daytime as well. Stretching and massaging the muscle usually relieves the cramps, but tenderness and pain can remain for days afterward in some patients.

Leg cramps increase with aging. Nightly leg cramping occurs in about 6% of adults older than 60 years of age. Two reasons this may occur more in this population is because there are more potential illnesses and medication uses in this population, which could cause cramping. Diabetes mellitus, amyotrophic lateral sclerosis, peripheral vascular disease, neuromuscular disorders, metabolic disorders, hypomagnesemia, hypokalemia, and hypocalcemia can all cause cramping. Medications associated with nocturnal cramping include oral contraceptives, diuretics, long-acting Beta agonists, and statins.

One big issue I address is whether the patient is drinking enough water. Patients often get up in the morning, have their coffee, and then continue throughout the day drinking other caffeinated beverages. They are in essence dehydrating themselves all day without replenishing with water. Often changing this bad habit can make a difference.

There are other reasons for cramping in general. Pregnant women often get cramps. This  usually subsides once the baby is born. Patients with hypothyroidism often complain of cramping. Exercise, prolonged standing, and reduced mobility can also be culprits.

Nocturnal leg cramping is still not well understood, and treatments are not well tested. One interesting anecdotal treatment that I have heard about from patients is taking a tablespoon of yellow mustard when cramping. One patient reports that any time he visits a fast food restaurant, he grabs extra mustard packets to keep in his shirt pocket in case of cramps. I have no answer as to why this would work unless it is a placebo effect, but if it works, then who am I to keep them from eating mustard?

Quinine sulfate was once touted as the cure for nocturnal leg cramping but has gone out of favor. In 2010, the FDA announced that over a 3-year period, it had received 38 reports of serious side effects resulting from quinine use. It is, however, still used in the United Kingdom for nocturnal leg cramps. Patients will drink tonic water for the quinine that it contains, although the amount of quinine in the drink is very small. I do educate my patients about the risks of using quinine for leg cramping.

Stretching before bed can help with cramps. Gabapentin has shown to be helpful in some cases. In sleep, we sometimes use the dopamine agonists ropinirole and pramipexole for leg cramps.

More research needs to be done to find the best treatment for this common pain-producing malady. Have you found something that has been really helpful? If so, please share.

Sharon M. O'Brien, MPAS, PA-C, is a practicing clinician with an interest is helping patients understand the importance of sleep hygiene and the impact of sleep on health.

Reference

  1. International classification of sleep disorders, 3rd edition. American Academy of Sleep Medicine, 2014.
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