Dear Dr. Roach: Would you discuss causes of nocturnal leg cramps? I have exhausted all of the common remedies without success.
R.S., M.D.
Leg cramps are common. They begin suddenly and affect the calf or foot with an involuntary, painful contraction. The muscle becomes tight and hard, and it is relieved by stretching the muscle, especially by standing or walking. The most common cause of leg cramps at night is “idiopathic,” which is Greek for “one’s own disease,” meaning we do not know the cause. There are some risk factors, such as having flat feet and being sedentary.
However, people with nocturnal leg cramps should be evaluated for common conditions that cause symptoms of leg pain, cramping or discomfort. Restless leg syndrome in particular can cause leg discomfort and involuntary movements. People with blockages in the arteries of the legs also might have pain and cramping, though these occur with movement rather than at rest in bed.
Other conditions that often are associated with nocturnal leg cramps include neurological diseases such as Parkinson’s; abnormalities in electrolytes, such as calcium, magnesium or sodium; and metabolic diseases, such as diabetes and hypothyroidism. Some medications appear to predispose a person to leg cramps, especially some asthma medicines (like salmeterol, a component of Advair) and some types of diuretics, such as hydrochlorothiazide.
I know you have tried common remedies, but let me include them here anyway. Stretch the muscles several times daily, including in the evening and just before bed. To do this, keep the heel flat while leaning forward for 10 to 20 seconds. Hamstring stretches also may be helpful in preventing cramps. Shoes with more support in the heel (ask for a “long-countered shoe”) are better.
Avoid alcohol, caffeine and dehydration.
Some of the less common remedies may still be effective. These include vitamin B complex, iron for those with iron deficiency, and possibly magnesium supplements. On occasion, I have seen verapamil, a prescription medicine normally used for high blood pressure, be effective.
Many people have written to me about the effectiveness of quinine. Quinine is not recommended, as it can cause serious side-effects, including low platelets and abnormal heart rhythms. Six ounces of tonic water is a way to get a low, but hopefully effective, dose of quinine, but people who use this should know about the potential for bleeding and drug interactions.
Dear Dr. Roach: In your recent column, you stated that “long-acting” agents — such as salmeterol, formoterol or steroid inhalers — are not useful in an asthma attack. It is correct that salmeterol and inhaled steroids are not appropriate choices, but formoterol, while long-acting, has a rapid onset of action similar to albuterol, and is included in the Global Initiative for Asthma guidelines as an appropriate alternative in an emergency. Please correct the inhaler information, as many patients with asthma may lose confidence in their providers who have correctly told them that formoterol can be used if needed.
R.L.
I appreciate the information. I further reviewed this and found that the letter writer is correct. Formoterol can be used as a short-acting or “rescue” inhaler. I apologize for the error.
Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to [email protected].
