A 76 year old woman presented to her general practitioner with a four year history of uncomfortable sensations in her legs like “swarms of biting and crawling ants.” These would occur in the evenings and were worse when she was sitting still or lying in bed at night. Relief could be obtained only by moving her legs or getting out of bed. This caused severe insomnia and was adversely affecting her quality of life. She had no family history of movement disorders but had osteoarthritis and gout, and was taking allopurinol plus calcium and vitamin D supplements.

She was started on co-beneldopa 25/100 (benserazide 25 mg, levodopa 100 mg) and ropinirole 2 mg nightly for her leg symptoms and nitrazepam 5 mg for her insomnia. She initially had some mild relief, but because her symptoms were not fully controlled the doses were increased. After one month of dose escalation, her symptoms became more severe, lasted longer during the night, and affected her sleep more severely than before. In an attempt to control her symptoms, her doses were increased further until she was taking co-beneldopa and ropinirole four hourly. However, she then developed severe symptoms during the daytime, from the mornings onwards, which were exacerbated by taking long car journeys. She was referred to the neurology clinic for a further opinion.