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# Rizatriptan
## Overview
Rizatriptan is a selective serotonin 5-HT1B/1D receptor agonist used for the acute treatment of migraine headaches with or without aura. It acts via cranial vessel vasoconstriction and inhibition of proinflammatory neuropeptide release.
## Primary Indications
Acute treatment of migraine attacks in adults and pediatric patients (6 to 17 years). It is not intended for the prophylactic therapy of migraine or for the treatment of hemiplegic or basilar migraine.
## Adult Dosing
* **Initial Dose:** 5 mg or 10 mg orally.
* **Redosing:** If the migraine recurs after initial relief, a second dose may be administered 2 hours after the first.
* **Maximum Dose:** 30 mg in a 24-hour period.
## Pediatric Dosing
* **Weight 25 kg to <40 kg:** 5 mg orally.
* **Weight ≥40 kg:** 10 mg orally.
* **Redosing:** A second dose may be administered 2 hours after the first if needed.
* **Maximum Dose:** Do not exceed 2 doses in a 24-hour period. Safety data for exceeding this frequency is limited.
## Dose Adjustments
* **Propranolol Use:** Patients taking propranolol should use the 5 mg dose of rizatriptan due to increased plasma concentrations. The maximum 24-hour dose in these patients is 15 mg.
* **Renal/Hepatic Impairment:** Use with caution in patients with moderate hepatic or renal impairment; lower doses (5 mg) are recommended. Use is not recommended in severe hepatic impairment.
## Contraindications
* History of ischemic heart disease (angina pectoris, MI, silent ischemia).
* Coronary artery vasospasm (Prinzmetal’s angina).
* Uncontrolled hypertension.
* Wolff-Parkinson-White syndrome or arrhythmias associated with other cardiac accessory conduction pathway disorders.
* 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.
* Concurrent use or within 2 weeks of discontinuing MAO inhibitors.
## Adverse Effects
* **Common:** Dizziness, somnolence, paresthesia, fatigue, and dry mouth.
* **Serious:** Coronary artery vasospasm, myocardial infarction, arrhythmias, and serotonin syndrome (especially when combined with SSRIs/SNRIs).
## Key Drug Interactions
* **MAO Inhibitors:** Risk of significant hypertension and serotonin syndrome.
* **Propranolol:** Increases rizatriptan exposure; dose reduction required.
* **SSRIs/SNRIs:** Potential for serotonin syndrome (use with caution; monitor for symptoms such as agitation, tachycardia, or tremors).
* **Ergots:** Contraindicated within 24 hours due to additive vasoconstrictive effects.
## Monitoring
* **Cardiovascular:** Monitor for cardiac chest pain or symptoms of ischemia, particularly in patients with cardiovascular risk factors (e.g., postmenopausal women, men >40, uncontrolled HTN, obesity, diabetes).
* **Serotonin Syndrome:** Assess for mental status changes and autonomic instability if combined with other serotonergic agents.
## Clinical Pearls
* **Administration:** The orally disintegrating tablet (ODT) can be taken without water; ensure the blister pack is dry before removing the tablet and place it immediately on the tongue.
* **Efficacy:** Effectiveness is generally highest when taken as early as possible after the onset of migraine symptoms.
* **Medication Overuse:** Frequent use (≥10 days/month) can lead to medication-overuse headache (rebound headache).
* **Local Protocols:** Institutional guidelines may dictate specific weight-based cutoffs for pediatric dosing; always verify against local formulary requirements.
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**Disclaimer:** This information is for educational purposes only. Always consult current clinical practice guidelines, the manufacturer’s package insert, or a pharmacist to verify prescribing information and drug compatibility before administration.
