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# Rizatriptan
## Overview
Rizatriptan is a selective serotonin 5-HT1B/1D receptor agonist used for the acute treatment of migraine attacks. It is available as a conventional tablet and an orally disintegrating tablet (ODT).
## Primary Indications
Acute treatment of migraine with or without aura in adults and pediatric patients. It is not indicated for migraine prophylaxis or the treatment of hemiplegic or basilar migraine.
## Adult Dosing
* **Initial Dose:** 5 mg or 10 mg at onset of migraine.
* **Maximum Dose:** 30 mg in a 24-hour period.
* **Dose Intervals:** If symptoms persist or return, a second dose may be taken at least 2 hours after the first.
* **Note:** Use 5 mg for patients taking propranolol (see Dose Adjustments).
## Pediatric Dosing
Approved for children aged 6 to 17 years.
* **Weight < 40 kg:** 5 mg once per attack.
* **Weight ≥ 40 kg:** 10 mg once per attack.
* **Safety/Max:** Pediatric frequency is generally limited to one dose per 24 hours; consult institutional guidelines for specific repeating protocols.
## Dose Adjustments
* **Propranolol:** Patients receiving propranolol must use 5 mg as the dose, capped at a maximum of 15 mg per 24 hours.
* **Renal/Hepatic Impairment:** Reduce dose to 5 mg for patients with moderate hepatic or severe renal impairment.
## Contraindications
* History of ischemic heart disease, coronary artery vasospasm (Prinzmetal’s angina), or uncontrolled hypertension.
* History of myocardial infarction, stroke, or TIA.
* Use within 24 hours of another 5-HT1 agonist or ergotamine-type medication.
* Use within 2 weeks of monoamine oxidase inhibitor (MAOI) therapy.
* Wolff-Parkinson-White syndrome or arrhythmias associated with cardiac accessory conduction pathways.
## Adverse Effects
* **Common:** Paresthesia, dizziness, somnolence, fatigue, and sensations of pressure, pain, or tightness in the chest/neck (triptan sensations).
* **Serious:** Coronary vasospasm, myocardial ischemia, arrhythmias, serotonin syndrome, and cerebral hemorrhage.
## Key Drug Interactions
* **MAOIs:** Significantly increase plasma concentration of rizatriptan; contraindicated.
* **SSRIs/SNRIs:** Potential for serotonin syndrome (increased risk with concomitant triptan use).
* **Propranolol:** Increases rizatriptan blood levels by inhibiting metabolism.
## Monitoring
* Monitor cardiovascular status, especially in patients with cardiovascular risk factors (consider ECG for first dose in high-risk patients).
* Monitor for signs of serotonin syndrome (agitation, tremor, hyperreflexia, autonomic instability).
* Frequency of use: Monitor for medication-overuse headache (MOH) if used >10 days per month.
## Clinical Pearls
* **Timing:** Administer as soon as migraine symptoms begin; efficacy is not established if taken during the aura phase prior to headache onset.
* **ODT Formulation:** The orally disintegrating tablet (Maxalt-MLT) should be placed on the tongue and allowed to dissolve; no water is required. It is not equivalent to a faster onset of action but is useful for patients with nausea.
* **Cardiac Risk:** In patients with risk factors, the first dose should be administered in a setting where cardiac diagnostic tools are available.
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**Educational Disclaimer:** This information is for educational purposes only. Clinical practice is subject to change. Always verify current prescribing information, institutional protocols, and patient-specific factors with verified manufacturer labels or clinical decision support tools before prescribing or administering medication.
