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# Rizatriptan
## Overview
Rizatriptan is a selective serotonin (5-HT1B/1D) receptor agonist. It acts by agonizing receptors on intracranial blood vessels and sensory nerves of the trigeminal system, resulting in cranial vessel constriction and inhibition of pro-inflammatory neuropeptide release.
## Primary Indications
Acute treatment of migraine with or without aura in adults and pediatric patients (aged 6 to 17 years).
## Adult Dosing
* **Initial Dose:** 5 mg or 10 mg.
* **Maximum Dose:** 30 mg in a 24-hour period.
* **Repeat Dosing:** If symptoms return, a second dose may be taken at least 2 hours after the initial dose.
* **Orally Disintegrating Tablets (ODT):** Should be placed on the tongue and allowed to dissolve; no liquid is required.
## Pediatric Dosing
Dosing is weight-based for patients aged 6 to 17 years:
* **Weight < 40 kg:** 5 mg.
* **Weight ≥ 40 kg:** 10 mg.
* **Maximum Dose:** A single dose is recommended; efficacy of a second dose has not been established in pediatric populations.
## Dose Adjustments
* **Renal Impairment:** No specific adjustment required.
* **Hepatic Impairment:** Safety not established in severe impairment; use caution.
* **Patients on Propranolol:** Reduce dose to 5 mg (maximum 15 mg/24 hours) due to increased rizatriptan plasma concentrations.
## Contraindications
* History of ischemic heart disease, coronary artery vasospasm (Prinzmetal’s angina), or symptomatic Wolff-Parkinson-White syndrome.
* History of stroke or transient ischemic attack (TIA).
* Peripheral vascular disease.
* Uncontrolled hypertension.
* Administration within 24 hours of another 5-HT1 agonist or ergotamine-type medication.
* Use within 2 weeks of monoamine oxidase inhibitor (MAOI) therapy.
## Adverse Effects
* **Common:** Dizziness, somnolence, paresthesia, fatigue, and chest discomfort/heaviness (usually non-cardiac).
* **Serious:** Coronary vasospasm, myocardial infarction, arrhythmias, and serotonin syndrome (especially when combined with SSRIs/SNRIs).
## Key Drug Interactions
* **Propranolol:** Increases rizatriptan exposure; requires dose limitation.
* **Serotonergic Drugs (SSRIs, SNRIs, TCAs, St. John’s Wort):** Increases risk of serotonin syndrome; monitor closely.
* **Ergot-containing medications:** Additive vasospastic effects; separate by at least 24 hours.
* **MAOIs:** Contraindicated; risk of significant hypertension/serotonin toxicity.
## Monitoring
* Monitor cardiovascular status in patients with multiple risk factors (postmenopausal, men >40, smokers, diabetics, hypercholesterolemia) before initial prescription.
* Observe for signs of serotonin syndrome (agitation, tachycardia, hyperreflexia).
* Assess for medication overuse headache if used >10 days/month.
## Clinical Pearls
* Clinical efficacy is higher when administered early in the migraine attack.
* The ODT formulation does not offer a faster onset of action than the tablet but is useful for patients with nausea or lack of access to water.
* Chest symptoms are common but should be evaluated to rule out cardiac ischemia if symptoms are severe, persistent, or worsening.
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**Disclaimer:** This information is for educational purposes only. Always verify current prescribing information, dosing guidelines, and institutional protocols before administering any medication.
