Tramadol for Refractory Restless Legs Syndrome Following Methadone Intolerance: A Case Report.

Restless legs syndrome (RLS) refractory to guideline-directed therapy may require treatment with low-dose opioids. Methadone is an established option for refractory RLS but may be limited by medication intolerance. We present a 52-year-old woman with refractory RLS who failed multiple pharmacologic therapies, including ropinirole, carbidopa/levodopa, gabapentin, and pregabalin. Methadone produced excellent symptom control but was discontinued because of dysphoria, emotional lability, cognitive slowing, and persistent daytime grogginess. Transition to tramadol 50 mg nightly resulted in sustained symptom control without recurrence of these adverse effects, allowing discontinuation of gabapentin and improved daytime functioning. This case highlights the importance of individualized opioid selection in refractory RLS and suggests that tramadol may be an effective alternative for carefully selected patients with methadone intolerance.