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# Rizatriptan
## Overview
Rizatriptan is a selective serotonin (5-HT1B/1D) receptor agonist used for the acute treatment of migraine. It exhibits faster absorption (by mouth) compared to other triptans and undergoes metabolism primarily via monoamine oxidase-A (MAO-A).
## Primary Indications
Acute treatment of migraine attacks with or without aura in adults and pediatric patients (aged 6 to 17 years). Not indicated for migraine prophylaxis or hemiplegic/basilar migraine.
## Adult Dosing
* **Initial Dose:** 5 mg or 10 mg.
* **Redosing:** May repeat dose after 2 hours if migraine persists.
* **Maximum Daily Dose:** 30 mg in a 24-hour period.
* *Note:* Use the 5 mg dose for patients taking propranolol.
## Pediatric Dosing
* **Weight < 40 kg:** 5 mg.
* **Weight ≥ 40 kg:** 10 mg.
* **Redosing:** May repeat dose once after 2 hours if needed.
* **Maximum Daily Dose:** Do not exceed one dose in a 24-hour period for children (based on current label pediatric evidence).
## Dose Adjustments
* **Renal/Hepatic Impairment:** Use with caution in mild-to-moderate impairment. Avoid in severe hepatic impairment.
* **Concurrent Medications:** Limit to 5 mg if the patient is on concurrent propranolol therapy (propranolol increases rizatriptan plasma concentrations).
## Contraindications
* History of ischemic heart disease, coronary artery vasospasm (Prinzmetal's angina), or silent ischemia.
* Wolff-Parkinson-White syndrome or arrhythmias associated with accessory conduction pathways.
* 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 ergot-type medication.
* Use within 2 weeks of discontinuing a monoamine oxidase inhibitor (MAOI).
## Adverse Effects
* **Common:** Paresthesia, dizziness, somnolence, fatigue, and sensations of pressure/tightness in the chest or throat.
* **Severe:** Coronary artery vasospasm, myocardial infarction, serotonin syndrome (especially with SSRIs/SNRIs), and hypertensive crisis.
## Key Drug Interactions
* **MAO Inhibitors:** Risk of significantly elevated rizatriptan levels; avoid combination.
* **Propranolol:** Increases rizatriptan AUC/Cmax; limit rizatriptan dose to 5 mg.
* **SSRIs/SNRIs:** Potential for serotonin syndrome (clinical data is mixed, monitor for symptoms).
* **Ergot derivatives:** Risk of additive vasospastic effects; separate dosing by 24 hours.
## Monitoring
* Monitor blood pressure during the first dose, especially in patients with cardiovascular risk factors.
* Assess for evidence of overuse (medication-overuse headache) if used >10 days/month.
* Observe for signs/symptoms of serotonin syndrome (agitation, tachycardia, hyperreflexia).
## Clinical Pearls
* **Administration:** Orally disintegrating tablets (ODTs) should be placed on the tongue and allowed to dissolve; water is not required.
* **Efficacy:** Effectiveness is best if taken at the onset of migraine symptoms.
* **Cardiovascular Risk:** In "low-risk" patients, the first dose may be administered in a clinical setting to assess for cardiac response; avoid in patients with high Framingham risk scores without prior cardiac evaluation.
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**Educational Disclaimer:** This information is for educational purposes only. Always verify dosing, contraindications, and drug interactions against current prescribing information (e.g., electronic health records, FDA-approved labels, or clinical pharmacology databases) before prescribing or administering medication.
