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# Rizatriptan
## Overview
Rizatriptan is a selective serotonin (5-HT1B/1D) receptor agonist used for the acute treatment of migraine. It is available as standard tablets and orally disintegrating tablets (ODT).
## Primary Indications
* Acute treatment of migraine with or without aura in adults and pediatric patients (≥6 years).
## Adult Dosing
* **Initial Dose:** 5 mg or 10 mg at onset of migraine.
* **Max Dose:** 30 mg in a 24-hour period.
* **Dosing Interval:** If symptoms persist or return, a second dose may be taken no sooner than 2 hours after the first.
* **Note:** If no response to the first dose, the benefit of a second dose for the same attack has not been established.
## Pediatric Dosing
* **6 to 11 Years:** 5 mg once per single migraine attack.
* **≥12 Years:** Follow adult dosing (5 mg or 10 mg).
* **Max Dose:** 5 mg (for 6–11 years) or 10 mg (for ≥12 years) per 24 hours.
## Dose Adjustments
* **Propranolol:** Patients taking propranolol should use a reduced dose of 5 mg (Max: 15 mg/24 hours) as propranolol increases rizatriptan plasma concentrations.
* **Renal/Hepatic Impairment:** No specific adjustment is mandated by labeling, but caution is advised in severe hepatic impairment.
## Contraindications
* History of ischemic heart disease, coronary artery vasospasm (Prinzmetal angina), or current coronary artery disease.
* History of stroke or transient ischemic attack (TIA).
* Peripheral vascular disease or ischemic bowel disease.
* Uncontrolled hypertension.
* Administration within 24 hours of another 5-HT1 agonist or ergotamine-type medication.
* MAOI use within the last 2 weeks.
## Adverse Effects
* **Common:** Dizziness, somnolence, paresthesia, fatigue, and dry mouth.
* **Serious:** Coronary vasospasm, transient myocardial ischemia, arrhythmias, serotonin syndrome (when used with serotonergic agents), and medication overuse headache.
## Key Drug Interactions
* **MAOIs:** Significant risk of elevated rizatriptan levels; contraindication is strict.
* **Serotonergic Agents (SSRIs, SNRIs, TCAs):** Potential risk of serotonin syndrome; monitor for symptoms (agitation, tremor, hyperreflexia).
* **Propranolol:** Increases area under the curve (AUC) of rizatriptan by ~70%.
## Monitoring
* Assess for cardiovascular symptoms (chest pain/tightness) after the first dose.
* Monitor blood pressure periodically in patients with cardiac risk factors.
* Observe for signs/symptoms of serotonin syndrome if combined with other serotonergic medications.
## Clinical Pearls
* **ODT Formulation:** Should be dissolved on the tongue; no water is required. It is not recommended for patients with phenylketonuria (contains phenylalanine).
* **Efficacy:** Effectiveness is generally greater when the drug is administered at the earliest onset of pain.
* **Cardiac Evaluation:** In patients with risk factors (postmenopausal, men >40, uncontrolled HTN, DM, obesity), perform a cardiovascular evaluation before starting therapy.
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**Educational Disclaimer:** This information is for educational purposes only. Always consult current prescribing information (e.g., FDA-approved label) and institutional protocols before prescribing or administering medication. Clinical judgment should be used based on individual patient circumstances.
