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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 acts by causing vasoconstriction of intracranial blood vessels and inhibiting the release of pro-inflammatory neuropeptides. It is available as standard tablets and orally disintegrating tablets (ODT). ## Primary Indications Acute treatment of migraine attacks with or without aura in adults and pediatric patients (6–17 years). Not indicated for migraine prophylaxis or the treatment of hemiplegic or basilar migraine. ## Adult Dosing * **Initial Dose:** 5 mg or 10 mg at the onset of migraine symptoms. * **Redosing:** If headache recurs or if there is no response, a second dose may be taken no earlier than 2 hours after the initial dose. * **Maximum Daily Dose:** 30 mg in a 24-hour period. ## Pediatric Dosing * **Children 6 to 17 years:** * Weight < 40 kg: 5 mg single dose. * Weight ≥ 40 kg: 10 mg single dose. * **Redosing:** Pediatric safety data for a second dose within a 24-hour period is limited; local protocols vary, but generally, only one dose per 24 hours is recommended due to lack of longitudinal safety data in this population. ## Dose Adjustments * **Renal Impairment:** No dosage adjustment needed. * **Hepatic Impairment:** Use with caution in mild to moderate hepatic impairment. * **Concomitant Propranolol:** Dose reduction is required. Administer 5 mg; the maximum daily dose should not exceed 15 mg (three 5 mg doses). Propranolol increases the plasma concentration of rizatriptan. ## Contraindications * History of ischemic heart disease (e.g., angina, myocardial infarction). * Coronary artery vasospasm (Prinzmetal’s angina). * Wolff-Parkinson-White syndrome or arrhythmias associated with cardiac accessory conduction pathways. * History of stroke or transient ischemic attack (TIA). * Peripheral vascular disease. * Uncontrolled hypertension. * Hemiplegic or basilar migraine. * Administration within 24 hours of another 5-HT1 agonist or ergotamine-type medication. * Use within 2 weeks of discontinuing MAO-A inhibitors. ## Adverse Effects * **Common:** Paresthesia, somnolence, dizziness, fatigue, nausea, dry mouth. * **Serious (Rare):** Coronary artery vasospasm, myocardial ischemia, arrhythmias, serotonin syndrome (if combined with serotonergic agents), or stroke. ## Key Drug Interactions * **MAO-A Inhibitors:** Potentiates rizatriptan levels; contraindicated. * **Propranolol:** Increases rizatriptan exposure; requires dose limitation. * **SSRIs/SNRIs:** Potential for serotonin syndrome (use with caution and monitor for clinical signs). * **Ergot-containing drugs:** Additive risk of prolonged vasospastic reactions; avoid within 24 hours. ## Monitoring * Monitor cardiovascular status in patients with multiple risk factors (e.g., post-menopausal, males >40, smokers, diabetics) at the first dose. * Monitor for neurological changes suggesting serotonin syndrome if combined with other CNS-active substances. ## Clinical Pearls * **ODT Formulation:** The orally disintegrating tablet should be placed on the tongue and allowed to dissolve; no liquid is required. It is not faster-acting than the oral tablet but may be preferred for patients with severe nausea. * **Medication Overuse Headache (MOH):** Excessive use (typically >10 days per month) of triptans can lead to medication overuse headache. * **Delayed Efficacy:** If the first dose produces no response, the patient should be re-evaluated before attempting future doses to rule out alternative diagnoses. *** *Disclaimer: This information is for educational purposes. Always verify current prescribing information, institutional protocols, and patient-specific factors via reliable clinical databases (e.g., Lexicomp, UpToDate) before prescribing or administering medication.*