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# Rizatriptan
## Overview
Rizatriptan is a selective serotonin (5-HT1B/1D) receptor agonist used for the acute treatment of migraine. It acts via cranial vessel constriction, inhibition of neuropeptide release, and reduction of pain signal transmission via the trigeminal nuclei.
## Primary Indications
Acute treatment of migraine attacks with or without aura in adults and pediatric patients.
## Adult Dosing
* **Initial Dose:** 5 mg or 10 mg orally at the onset of migraine.
* **Repeat Dose:** If symptoms persist or return, a second dose may be taken at least 2 hours after the first.
* **Maximum Dose:** 30 mg per 24-hour period.
* **Note:** Orally disintegrating tablets (ODT) should be placed on the tongue and allowed to dissolve without liquid.
## Pediatric Dosing
* **Ages 6 to 17 years:**
* **Weight < 40 kg:** 5 mg single dose.
* **Weight ≥ 40 kg:** 10 mg single dose.
* **Note:** Safety and efficacy of a second dose in children have not been established; generally limited to one dose per 24 hours.
## Dose Adjustments
* **Propranolol:** Patients taking propranolol should use a maximum single dose of 5 mg and a maximum of 15 mg per 24 hours due to increased rizatriptan plasma concentrations.
* **Renal/Hepatic Impairment:** Use with caution in moderate hepatic or renal impairment; consider the 5 mg dose. Avoid in severe hepatic impairment.
## Contraindications
* History of ischemic heart disease, coronary artery vasospasm (Prinzmetal angina), or current symptoms/signs of CAD.
* History of stroke or transient ischemic attack (TIA).
* Peripheral vascular disease or ischemic bowel disease.
* Uncontrolled hypertension.
* Hemiplegic or basilar migraine (risk of stroke).
* Use within 24 hours of another 5-HT1 agonist or ergotamine-type medication.
* Use within 2 weeks of monoamine oxidase inhibitor (MAOI) therapy.
## Adverse Effects
* **Common:** Paresthesia, dizziness, somnolence, fatigue, and dry mouth.
* **Severe (Rare):** Coronary vasospasm, myocardial infarction, arrhythmias, serotonin syndrome (especially if combined with SSRIs/SNRIs), and hypertensive crisis.
## Key Drug Interactions
* **MAOIs:** Absolute contraindication due to increased risk of serotonin syndrome and elevated rizatriptan levels.
* **SSRI/SNRI antidepressants:** Risk of serotonin syndrome (monitor for symptoms).
* **Propranolol:** Increases rizatriptan exposure (use dose reduction).
* **Ergot-containing drugs:** Increased risk of vasospastic effects; separate doses by at least 24 hours.
## Monitoring
* Monitor cardiovascular status in patients with multiple risk factors (e.g., postmenopausal women, smokers, uncontrolled hypertension, hypercholesterolemia).
* Monitor for signs of serotonin syndrome (agitation, tremor, tachycardia, diaphoresis) if taken with serotonergic agents.
## Clinical Pearls
* Treatment efficacy is generally higher when the drug is taken as soon as head pain begins.
* Rizatriptan is not indicated for the prophylaxis of migraines or for cluster headaches.
* Patients should be cautioned that overuse of acute migraine medications (≥10 days/month) can lead to medication overuse headache (rebound headache).
* ODT formulations do not offer a faster onset of action than conventional tablets; they are indicated for convenience in patients with nausea/vomiting.
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**Disclaimer:** This information is for educational purposes only. Always verify current prescribing information, contraindications, and local protocols through authorized clinical databases (e.g., Lexicomp, UpToDate) or the manufacturer's package insert before prescribing or administering medication.
