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# Rizatriptan
## Overview
Rizatriptan is a selective serotonin 5-HT1B/1D receptor agonist used for the acute treatment of migraine. It exhibits faster onset and slightly higher efficacy than some other triptans due to its favorable pharmacokinetic profile.
## Primary Indications
Acute treatment of migraine attacks with or without aura in adults and pediatric patients (ages 6–17 years). It is not indicated for migraine prophylaxis or the treatment of hemiplegic or basilar migraine.
## Adult Dosing
* **Initial Dose:** 5 mg or 10 mg orally.
* **Dosing Interval:** If symptoms return, or if there is no response, a second dose may be administered at least 2 hours after the first.
* **Maximum Dose:** 30 mg in a 24-hour period.
* **Note:** Orally disintegrating tablets (ODTs) should be placed on the tongue and allowed to dissolve; no liquid is required.
## Pediatric Dosing
* **Ages 6 to 17 years:**
* Weight < 40 kg: 5 mg.
* Weight ≥ 40 kg: 10 mg.
* **Dosing Interval:** May repeat once after 2 hours if migraine persists.
* **Maximum Dose:** Limited to one dose per 24-hour period in many clinical settings; consult local institutional protocols for specific pediatric dosing limits.
## Dose Adjustments
* **Propranolol Users:** Propranolol increases rizatriptan plasma concentrations. The dose should be reduced: 5 mg maximum per dose, not to exceed 15 mg in 24 hours.
* **Renal/Hepatic Impairment:** Use with caution. Consider 5 mg starting dose in patients with moderate hepatic or severe renal impairment.
## Contraindications
* History of ischemic heart disease, coronary artery vasospasm (Prinzmetal’s angina), or myocardial infarction.
* History of stroke or transient ischemic attack (TIA).
* Peripheral vascular disease or ischemic bowel disease.
* Uncontrolled hypertension.
* Within 24 hours of another 5-HT1 agonist or ergotamine-type medication.
* Within 2 weeks of MAO-A inhibitor therapy.
## Adverse Effects
* **Common:** Dizziness, somnolence, paresthesia, fatigue, warm/cold sensations, and xerostomia (specifically with ODT formulations).
* **Serious:** Coronary vasospasm, transient myocardial ischemia, arrhythmias, serotonin syndrome (when combined with SSRIs/SNRIs).
## Key Drug Interactions
* **MAO Inhibitors:** Risk of significant hypertension and serotonin syndrome.
* **SSRIs/SNRIs:** Potential increased risk of serotonin syndrome.
* **Propranolol:** Significant risk of increased rizatriptan exposure (dose reduction required).
## Monitoring
* Monitor blood pressure during initial use in patients with risk factors for cardiovascular disease.
* Assess for "triptan sensations" (chest/throat tightness) which are usually non-cardiac, but monitor for signs of ischemia if symptoms persist or are severe.
* Avoid overuse to prevent medication-overuse headache (limit use to ≤10 days per month).
## Clinical Pearls
* Rizatriptan ODT contains phenylalanine; avoid in patients with phenylketonuria.
* Efficacy is maximized when the dose is taken as soon as a migraine starts.
* If a patient fails a trial of one triptan, they may successfully respond to a different agent in the class.
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**Disclaimer:** This information is for educational purposes only. Always verify dosing and contraindications against current clinical guidelines, FDA-approved prescribing information, or your institution's specific formulary protocols before prescribing or administering medication.
