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# Rizatriptan
## Overview
Rizatriptan is a selective serotonin 5-HT1B/1D receptor agonist (triptan) used for the acute treatment of migraine. It acts via cranial vessel vasoconstriction and inhibition of pro-inflammatory neuropeptide release. It is available as conventional tablets and orally disintegrating tablets (ODT).
## Primary Indications
Acute treatment of migraine attacks with or without aura in adults and pediatric patients. It is not indicated for the prophylactic treatment of migraine or for the treatment of hemiplegic or basilar migraine.
## Adult Dosing
* **Initial Dose:** 5 mg or 10 mg.
* **Dosing Interval:** If symptoms return or there is no satisfactory response, a second dose may be taken at least 2 hours after the first.
* **Maximum Dose:** 30 mg in a 24-hour period.
## Pediatric Dosing
* **Children 6–17 years (weight ≥40 kg):** 10 mg as a single dose.
* **Children 6–17 years (weight 20 to <40 kg):** 5 mg as a single dose.
* **Limit:** Do not exceed one dose in a 24-hour period for pediatric patients. Established based on FDA-approved labeling.
## Dose Adjustments
* **Propranolol Use:** Patients taking propranolol require dose reduction. Use 5 mg rizatriptan; maximum dose is 15 mg in 24 hours.
* **Hepatic/Renal Impairment:** Use with caution. Consider initial 5 mg dose in patients with mild to moderate impairment. Not recommended for use in patients with severe hepatic impairment.
## Contraindications
* History of ischemic heart disease (e.g., angina, myocardial infarction).
* Coronary artery vasospasm (Prinzmetal’s angina).
* Uncontrolled hypertension.
* History of stroke or transient ischemic attack (TIA).
* Peripheral vascular disease.
* Ischemic bowel disease.
* Administration within 24 hours of another 5-HT1 agonist or ergotamine-type medication.
* Administration within 14 days of monoamine oxidase inhibitor (MAOI) therapy.
## Adverse Effects
* **Common:** Paresthesia, dizziness, somnolence, fatigue, and pain/pressure sensations (often chest, neck, or throat).
* **Serious:** Coronary artery vasospasm, transient myocardial ischemia, arrhythmias, and serotonin syndrome (rare, especially if combined with SSRIs/SNRIs).
## Key Drug Interactions
* **MAOIs:** Increased rizatriptan plasma concentrations; strictly contraindicated.
* **Propranolol:** Increases rizatriptan exposure; requires specific dose reduction.
* **SSRIs/SNRIs:** Potential for serotonin syndrome (clinical monitoring required).
* **Ergot derivatives:** Risk of additive vasospastic effects (separate administration by 24 hours).
## Monitoring
* Monitor blood pressure periodically, especially in patients with cardiovascular risk factors.
* Assess for signs of serotonin syndrome if used concurrently with serotonergic agents.
* Observe for signs or symptoms of ischemic heart disease or coronary vasospasm following the first dose.
## Clinical Pearls
* **Administration:** ODT formulation should be placed on the tongue and allowed to dissolve; no liquid is required. It is not more effective than the tablet, but convenient if nausea prevents swallowing.
* **Efficacy:** Effectiveness is best if taken at the onset of migraine. There is no evidence that a second dose is effective if the first dose failed to provide relief.
* **Medication Overuse Headache:** Frequent use (typically >10 days per month) may lead to medication overuse headache.
* **Uncertainty:** In patients with significant cardiovascular risk factors, an ECG or cardiac evaluation is recommended prior to the first dose, though local protocols vary.
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**Disclaimer:** This information is for educational purposes only. Always consult the most current official prescribing information (package insert) or institutional guidelines before prescribing or dispensing medication. Clinical judgment should be exercised based on individual patient assessment.
