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Leg cramps - unknown cause - Management
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What self-care advice should I give someone about managing idiopathic leg cramps?

  • Reassure the person that idiopathic leg cramps are common; they have no underlying cause and can resolve spontaneously.
  • Advise all people about self-care measures:
    • To alleviate an attack, advise stretching and massaging the affected muscle(s). For example, upon calf cramps straighten the leg and dorsiflex the ankle, or walk around on the heels for a few minutes.
    • To help reduce the frequency of attacks:
      • Do stretching exercises of the affected muscle(s) three times a day. If beneficial, continue indefinitely at an acceptable frequency.
      • When sleeping, try to stop toes from pointing downwards. For example, if lying supine prop the feet up (using a pillow), or if prone hang the feet over the end of the bed. Keep blankets loose.
    • Consider using analgesia if the muscle(s) is tender after a cramp. It is impractical to use analgesia during a cramp, as most attacks are short lived.
Additional information
  • Calf exercises: stand 1 metre from a wall. Lean forward with the arms outstretched to touch the wall and keep the soles of the feet flat on the floor. Hold for 5 seconds; repeat the exercise for 5 minutes, three times a day, especially before going to bed.
Basis for recommendation

CKS did not identify any national guidelines for the management of leg cramps in primary care. These recommendations are based on expert opinion from review articles [Miller and Layzer, 2005; Shaker et al, 2005].

  • Idiopathic nocturnal leg cramps have a relatively benign natural history, with no serious complications. Most cases will resolve spontaneously [Salih, 2001].
  • There are no controlled trials evaluating massage or stretching for acute cramps; nor evaluating sleeping positions for the prevention of cramps. However, some experts [Weiner and Weiner, 1980] believe such strategies are useful. Trials looking at massage and sleeping positions may be impractical.
  • The evidence for stretching exercises to prevent leg cramps is limited to an observational study [Daniell, 1979] and one randomized controlled trial (RCT). The RCT showed no benefit for stretching exercises compared with non-stretching exercises at 12 weeks [Coppin et al, 2005], however the participants were already on quinine, limiting the generalizability of the findings. Exercises are safe and are considered by experts to be helpful to people with leg cramps [Postgraduate Medicine, 2002].

Should I use quinine for treating leg cramps?

  • Quinine is generally not recommended for treating idiopathic leg cramps due to the poor benefit-to-risk ratio. However, a trial of quinine may be considered if self-care measures fail and leg cramps are frequent and affecting the person's quality of life:
    • Prescribe 200–300 mg (at bedtime) for 4–6 weeks.
    • Ask the person to monitor any benefit using a sleep and cramp diary.
    • If beneficial, continue for 3 months, then aim to stop treatment to reassess ongoing need. If further treatment is required, review every 3–6 months.
    • If no benefit is seen after 4 weeks, stop treatment.
  • For more information on the adverse effects, contraindications, and drug interactions of quinine see the British National Formulary (www.bnf.org).
Basis for recommendation

CKS did not identify any national guidelines on the indications for using quinine in the management of leg cramps in primary care. These recommendations are based on expert opinion from review articles [Miller and Layzer, 2005; Shaker et al, 2005].

  • Evidence from a systematic review [Man-Son-Hing et al, 1998] and two randomized controlled trials [Diener et al, 2002; Woodfield et al, 2005] suggests a reduced frequency in leg cramps with quinine, compared with placebo over a 4-week period.
  • There are no trials which have evaluated the long-term efficacy or safety of quinine use for leg cramps. Observational studies and case reports have raised concerns about the risk:benefit ratio with quinine, mainly at the higher doses used for treating malaria [Mackie and Davidson, 1995; DTB, 1996; Reddy et al, 2004]. Therefore, experts recommend a treatment trial with careful monitoring of efficacy and adverse effects [Butler et al, 2002].
  • The Medicines and Healthcare products Regulatory Agency (MHRA) has recently reminded prescribers that quinine is not a routine treatment of nocturnal leg cramps and should only be considered when cramps cause regular disruption of sleep. The MHRA advise that quinine should be stopped if no benefit is seen after 4 weeks of treatment [MHRA, 2010].

When should I refer someone with leg cramps?

  • Refer to the appropriate speciality (e.g. neurology, rheumatology) when an underlying cause is suspected which cannot be managed in primary care.
  • Consider a referral to general medicine if:
    • The diagnosis is in doubt.
    • Treatment in primary care fails and symptoms are affecting the person's quality of life.
Basis for recommendation

CKS could not identify any national guidelines on referral advice for leg cramps in primary care. These recommendations are based on expert opinion from review articles [Miller and Layzer, 2005; Shaker et al, 2005] and pragmatism.

  • A referral will allow further investigations (e.g. electromyography studies, muscle biopsy) to confirm or exclude an underlying cause for leg cramps. Specialists may then offer treatments (e.g. naftidrofuryl, diltiazem, vitamin B, vitamin E, magnesium, or verapamil) in addition to primary care measures.
  • The evidence for treatments that might be offered by a specialist is limited to small uncontrolled trials, and is currently of uncertain benefit [Young, 2007].

Prescriptions

For information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC) (http://emc.medicines.org.uk), or the British National Formulary (BNF) (www.bnf.org).

1st line: non-drug management

Age from 12 years onwards
Advice only: stretching exercises
Age: from 12 years onwards
Licensed use: no
Patient information: Leg cramps are common and often go away without treatment. To alleviate an attack, try stretching and massaging the affected muscle(s) e.g. in calf cramps straighten the leg and flex the ankle. To help reduce the frequency of attacks try doing stretching exercises of the affected muscle(s) three times a day. If this helps, continue indefinitely. When sleeping, try to stop your toes from pointing down for example by propping your feet up with a pillow, or hanging them over the bed. Keep blankets loose.

2nd line: quinine tablets

Age from 16 years onwards
Quinine sulphate tablets: 200mg at night
Quinine sulphate 200mg tablets
Take one tablet at night.
Supply 28 tablets.
Age: from 16 years onwards
NHS cost: £2.07
Licensed use: yes
Quinine sulphate tablets: 300mg at night
Quinine sulphate 300mg tablets
Take one tablet at night.
Supply 28 tablets.
Age: from 16 years onwards
NHS cost: £2.10
Licensed use: yes

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