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# Rizatriptan
## Overview
Rizatriptan is a selective serotonin (5-HT1B/1D) receptor agonist. It acts by causing vasoconstriction of intracranial blood vessels and inhibiting the release of proinflammatory neuropeptides. It is available as conventional tablets and orally disintegrating tablets (ODT).
## Primary Indications
Acute treatment of migraine with or without aura.
## Adult Dosing
* **Initial Dose:** 5 mg or 10 mg.
* **Dosing Interval:** If migraine persists or recurs, a second dose may be taken after at least 2 hours.
* **Maximum Dose:** 30 mg in any 24-hour period.
* **ODT Formulation:** No water is required; place on the tongue and allow to dissolve.
## Pediatric Dosing
* **Children 6 to 17 years:** Dosing is weight-based.
* **Weight < 40 kg:** 5 mg single dose.
* **Weight ≥ 40 kg:** 10 mg single dose.
* **Note:** Efficacy and safety for repeat dosing in pediatric patients have not been established; generally restricted to one dose per 24 hours.
## Dose Adjustments
* **Patients taking Propranolol:** Propranolol increases rizatriptan plasma concentrations. Limit dose to 5 mg (maximum 15 mg/24 hours).
* **Renal/Hepatic Impairment:** No specific adjustment required, but use with caution in severe hepatic impairment.
## Contraindications
* History of ischemic heart disease, coronary artery vasospasm (Prinzmetal’s angina), or symptomatic Wolff-Parkinson-White syndrome.
* History of stroke or transient ischemic attack (TIA).
* Peripheral vascular disease.
* Uncontrolled hypertension.
* Administration within 24 hours of another 5-HT1 agonist or ergot-type medication.
* Current or recent (within 2 weeks) use of monoamine oxidase (MAO) inhibitors.
## Adverse Effects
* **Common:** Dizziness, somnolence, paresthesia, fatigue, and dry mouth.
* **Serious:** Coronary vasospasm, transient myocardial ischemia, arrhythmias, and serotonin syndrome (especially when combined with SSRIs/SNRIs).
* **Sensory:** Feelings of tightness, pain, pressure, or heaviness in the chest, neck, or throat ("triptan sensations").
## Key Drug Interactions
* **MAO Inhibitors:** Risk of severe toxicity/hypertensive crisis.
* **Propranolol:** Significant increase in rizatriptan exposure.
* **Serotonergic Agents (SSRIs, SNRIs):** Potential risk of serotonin syndrome; monitor for autonomic instability, neuromuscular changes, and altered mental status.
* **Ergotamines:** Additive vasoconstrictive effects; avoid within 24 hours.
## Monitoring
* Assess for cardiovascular symptoms (chest pain, shortness of breath) after the first dose, especially in patients with cardiovascular risk factors.
* Monitor for signs of medication overuse headache (MOH) with frequent use (>10 days/month).
* Monitor for serotogenic symptoms if combined with other serotonin-modulating medications.
## Clinical Pearls
* **Timing:** Administer as soon as migraine symptoms begin; efficacy is significantly reduced if delayed.
* **ODT Administration:** The ODT formulation should be used immediately upon removing from the blister pack as it is moisture-sensitive.
* **Triptan Choice:** If a patient fails one triptan, switching to another (e.g., sumatriptan, zolmitriptan) may provide therapeutic benefit.
* **Patient Education:** Advise patients that "triptan sensations" (tight chest) are usually self-limiting, but they must seek urgent care if chest pain is intense or persistent.
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*Disclaimer: This information is for educational purposes only. Always verify current prescribing information, institutional guidelines, and drug compendia (e.g., Lexicomp, UpToDate) before prescribing or administering medication.*
