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# Rizatriptan
## Overview
Rizatriptan is a selective 5-HT1B/1D receptor agonist used for the acute treatment of migraine headaches with or without aura. It is available as standard tablets and orally disintegrating tablets (ODT).
## Primary Indications
Acute treatment of migraine attacks in adults and pediatric patients (aged 6 to 17 years). Not indicated for migraine prophylaxis.
## Adult Dosing
* **Initial Dose:** 5 mg or 10 mg at the onset of migraine.
* **Dose Intervals:** If symptoms persist or recur, dose may be repeated after a minimum of 2 hours.
* **Maximum Dose:** 30 mg per 24-hour period.
* **Note:** Use the 5 mg dose for patients taking propranolol.
## Pediatric Dosing
* **Weight < 40 kg:** 5 mg single dose.
* **Weight ≥ 40 kg:** 10 mg single dose.
* **Dose Intervals:** Limited evidence exists for repeat dosing in children; follow local institutional protocols as many clinicians restrict to a single dose per 24 hours in this population.
## Dose Adjustments
* **Hepatic Impairment:** Use with caution in mild to moderate impaired liver function. Avoid in severe hepatic impairment.
* **Renal Impairment:** No dosage adjustment typically required.
* **Concurrent Medications:** Limit dose to 5 mg if taking propranolol (propranolol increases rizatriptan plasma concentrations).
## Contraindications
* History or symptoms of ischemic heart disease, coronary artery vasospasm (Prinzmetal’s angina), or significant arrhythmias.
* History of stroke or transient ischemic attack (TIA).
* Peripheral vascular disease.
* Ischemic bowel disease.
* Uncontrolled hypertension.
* Use within 24 hours of another 5-HT1 agonist or ergotamine-type medication.
* Use within 2 weeks of monoamine oxidase (MAO) inhibitor therapy.
## Adverse Effects
* **Common:** Paresthesia, dizziness, somnolence, fatigue, dry mouth, nausea.
* **Serious (Rare):** Myocardial infarction, coronary artery vasospasm, transient myocardial ischemia, serotonin syndrome, hypertension.
## Key Drug Interactions
* **Propranolol:** Increases rizatriptan bioavailability; max dose is 5 mg.
* **SSRI/SNRIs:** Increased risk of Serotonin Syndrome.
* **Ergotamines/Triptans:** Additive vasoconstrictive effects if used within 24 hours.
* **MAO Inhibitors:** Significantly increases rizatriptan levels; strictly contraindicated.
## Monitoring
* Monitor blood pressure periodically after initial use in patients with cardiovascular risk factors.
* Observe for symptoms of serotonin syndrome (agitation, tachycardia, hyperreflexia).
* Assess for "medication overuse headache" if used more than 10 days per month.
## Clinical Pearls
* **ODT Administration:** The ODT formulation should be placed on the tongue and allowed to dissolve; no water is required. It is not necessarily faster-acting than the tablet but is useful for patients with nausea/vomiting.
* **Cardiovascular Safety:** If the patient has significant risk factors for coronary artery disease, the first dose should be administered in a setting where cardiovascular status can be evaluated.
* **Consistency:** Effectiveness may vary by migraine attack; failure to respond to one dose does not preclude response to future doses.
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**Educational Disclaimer:** This information is for educational purposes only. Clinical practice guidelines vary by institution and patient-specific factors. Always verify current, full prescribing information via official manufacturer labeling or authoritative databases (e.g., Lexicomp, UpToDate) before prescribing or administering medication.
