Restless Legs and Akathisia from Medications: How to Tell Them Apart and What to Do

Have you or someone you know been told they have anxiety-only to keep feeling like they can’t sit still, their legs are on fire, and their body is begging to move, even when they’re exhausted? It’s not just stress. It might be akathisia-a medication side effect that’s often mistaken for something else, and that mistake can make things far worse.

Restless legs syndrome (RLS) and akathisia both make you feel like you need to move. But they’re not the same. And confusing them can lead to dangerous treatment choices. If you’re on antipsychotics, metoclopramide, or even some antidepressants, this isn’t just a minor annoyance. It’s a red flag that needs to be recognized-and handled-right away.

What Akathisia Really Feels Like

Akathisia isn’t just fidgeting. It’s an unbearable inner restlessness that makes you feel like you’re trapped in your own skin. People describe it as an ache that won’t quit, a pressure building inside your legs, or the overwhelming urge to pace, rock, or shift your weight-even when you’re already moving.

It’s not voluntary. You don’t choose to move. You have to move. And if you try to stop, the discomfort grows worse. One patient described it as, "You ache with restlessness, so you feel you have to walk, to pace. And then as soon as you start pacing, the opposite occurs to you; you must sit and rest. Back and forth, up and down you go… you cannot get relief."

This isn’t just about legs. While RLS is mostly in the limbs, akathisia can hit your whole body. You’ll see people constantly crossing and uncrossing their legs, shifting from foot to foot, tapping their fingers, rocking in their chair, or pacing in place. It’s worse when sitting. It’s often at its worst in the first few weeks after starting or increasing a medication.

What Causes It?

Akathisia is most commonly caused by drugs that block dopamine in the brain. That includes:

• First-generation antipsychotics like haloperidol (Haldol)-these carry the highest risk
• Second-generation antipsychotics like risperidone and olanzapine
• Metoclopramide (Reglan), used for nausea and stomach issues
• Some SSRIs and SNRIs, especially when started or increased

It’s not about dosage alone. Even low doses can trigger it. And it doesn’t always show up right away. There are four types:

• Acute: Starts within days to weeks, lasts under 6 months
• Chronic: Lasts more than 6 months
• Tardive: Appears months or years after starting the drug
• Withdrawal: Comes on within weeks after stopping or cutting back

And here’s the scary part: if doctors mistake akathisia for anxiety, they often increase the very drug causing it. That’s like pouring gasoline on a fire. A 2017 study in the RACGP Journal showed a patient on haloperidol developed suicidal thoughts-only to improve completely after the drug was stopped.

How It’s Different from Restless Legs Syndrome

RLS and akathisia look similar. Both involve leg discomfort and the need to move. But they’re different in key ways:

That last point is critical. RLS is frustrating, but akathisia can be life-threatening. The distress is so severe that many patients say they’d rather have untreated psychosis than live with akathisia. A 2022 NAMI survey found 68% of people with medication-induced restlessness were first told they had anxiety-and 42% had their dose increased, making it worse.

How Doctors Miss It

Most primary care providers and even some psychiatrists aren’t trained to look for akathisia. They see someone fidgeting, pacing, or saying they’re "anxious," and they treat the anxiety-not the root cause.

But it’s not hard to spot. A simple 5-minute check can make all the difference:

1. Ask: "Do you have an inner sense of restlessness that makes you feel like you have to move, even if you’re tired?"
2. Observe: Are they constantly shifting weight, crossing/uncrossing legs, tapping feet, or pacing in place?
3. Check timing: Did this start within weeks of a new or increased medication?
4. Rule out RLS: Is it worse at night? Is there a family history or low iron?

The Barnes Akathisia Rating Scale (BARS) is the gold standard tool used by specialists. It scores both how the patient feels and what you can see. But even without the form, a good clinician can spot it just by watching and listening.

What to Do If You Have It

The first step is always stopping or reducing the medication causing it-if it’s safe to do so. For example, haloperidol-induced akathisia often clears up in 2-3 days after stopping. But if the antipsychotic is needed to control psychosis, you can’t just cut it cold.

Here’s what works:

• Reduce the dose-if possible, under medical supervision
• Switch medications-some antipsychotics like lumateperone (Caplyta) have lower akathisia risk
• Add propranolol-a beta-blocker, starting at 10 mg twice daily, helps many patients
• Try clonazepam-a low dose (0.5 mg at night) can calm the nervous system
• Use cyproheptadine-an antihistamine that’s shown promise in small studies

Important: Avoid dopamine agonists like ropinirole. They help RLS, but they make akathisia worse.

One patient in a 2017 case study went from feeling like she was "going crazy" to "back to myself" in three days after stopping haloperidol and starting clonazepam. That’s not rare. It’s predictable-if you know what you’re looking for.

The Bigger Picture

One in five people on first-generation antipsychotics get akathisia. One in ten on second-generation ones. That’s tens of thousands of people every year in the UK alone. And yet, only 37% of psychiatric clinics routinely screen for it.

The FDA has required warnings on antipsychotic labels since 2008. New drugs are being designed to avoid it. In 2023, a new app from the International Parkinson and Movement Disorder Society helped clinicians diagnose it faster. A 2024 study even showed AI could detect akathisia from video calls with 89% accuracy.

But knowledge hasn’t caught up. Many doctors still think it’s "just anxiety." That’s why patients end up on higher doses, feeling worse, and sometimes suicidal.

If you’re on an antipsychotic or metoclopramide and you feel this restless, burning, urgent need to move-don’t wait. Don’t assume it’s stress. Ask your doctor: "Could this be akathisia?" Bring this information. Push for a proper assessment. Your life might depend on it.

What to Ask Your Doctor

• "Could this restlessness be caused by my medication?"
• "Have you ruled out akathisia before assuming it’s anxiety?"
• "What’s my current medication’s risk for this side effect?"
• "Can we try lowering the dose or switching to one with less risk?"
• "Would propranolol or clonazepam be safe to try alongside my current meds?"

If your doctor dismisses you, ask for a referral to a movement disorder specialist or a psychiatrist with experience in medication side effects. This isn’t "all in your head." It’s a real, measurable, treatable condition.