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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 by causing vasoconstriction of intracranial blood vessels and inhibiting the release of pro-inflammatory neuropeptides.
## Primary Indications
Acute treatment of migraine attacks in adults and pediatric patients (6–17 years of age). Not indicated for prophylaxis or the treatment of hemiplegic or basilar migraine.
## Adult Dosing
* **Initial Dose:** 5 mg or 10 mg at the onset of migraine.
* **Repeat Dosing:** If symptoms persist or recur, dose may be repeated after 2 hours.
* **Maximum Dose:** 30 mg in a 24-hour period.
* **Note:** The 5 mg dose is recommended for patients taking propranolol.
## Pediatric Dosing
* **Weight < 40 kg:** 5 mg oral tablet or orally disintegrating tablet (ODT).
* **Weight ≥ 40 kg:** 10 mg oral tablet or ODT.
* **Frequency:** Single dose only; safety and efficacy of a second dose in Pediatrics have not been formally established.
## Dose Adjustments
* **Propranolol:** Concomitant use increases rizatriptan plasma concentrations. Limit dose to 5 mg (max 15 mg/24 hours).
* **Renal/Hepatic Impairment:** No specific criteria established, but use with caution in severe hepatic impairment or mild-to-moderate renal impairment due to potential for increased exposure.
## Contraindications
* History of ischemic coronary artery disease, coronary vasospasm (Prinzmetal's angina), or myocardial infarction.
* 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 ergotamine-type medication.
* Use within 2 weeks of discontinuing a monoamine oxidase inhibitor (MAOI).
## Adverse Effects
* **Common:** Paresthesia, dizziness, somnolence, fatigue, nausea, and sensation of warmth or tightness in the chest/neck (triptan sensations).
* **Serious:** Coronary artery vasospasm, transient myocardial ischemia, arrhythmias, serotonin syndrome (when used with SSRIs/SNRIs).
## Key Drug Interactions
* **MAOIs:** Inhibition of rizatriptan metabolism (contraindicated).
* **Propranolol:** Increases rizatriptan AUC (requires dose reduction).
* **SSRIs/SNRIs:** Increased risk of serotonin syndrome.
* **Ergotamines:** Additive vasoconstrictive effects (avoid within 24 hours).
## Monitoring
* Monitor blood pressure periodically in patients with cardiovascular risk factors.
* Assess for "triptan overuse headache" if used >10 days/month.
* Monitor for signs of serotonin syndrome if combined with serotonergic antidepressants.
## Clinical Pearls
* **ODT Formulation:** Rizatriptan ODT does not require water; the patient should place it on the tongue and allow it to dissolve. ODT packaging must be kept dry; do not remove from blister pack until immediately before dosing.
* **Onset:** Efficacy is independent of the time since migraine onset, though earlier administration is generally preferred.
* **Triptan Sensations:** Patients should be counseled that chest/throat tightness is usually non-cardiac in origin, but new or worsening symptoms should be investigated.
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*Educational Disclaimer: This information is for educational purposes only. Always consult current, verified package inserts, institutional protocols, or clinical drug databases (e.g., Lexicomp, UpToDate) before prescribing or administering medication.*
