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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 vasoconstriction and inhibition of pro-inflammatory neuropeptide release. ## 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 hemiplegic/basilar migraine. ## Adult Dosing * **Initial Dose:** 5 mg or 10 mg orally. Orally disintegrating tablets (ODT) should be placed on the tongue and allowed to dissolve. * **Dosing Interval:** If migraine persists or recurs, may repeat dose after 2 hours. * **Maximum Dose:** 30 mg in a 24-hour period. ## Pediatric Dosing (6–17 years) * **Weight < 40 kg:** 5 mg as a single dose. * **Weight ≥ 40 kg:** 10 mg as a single dose. * **Maximum Frequency:** Only one dose should be taken in a 24-hour period for pediatric patients. ## Dose Adjustments * **Hepatic/Renal Impairment:** No specific adjustment required for mild to moderate impairment; use caution in severe impairment (manufacturer labeling often suggests starting with 5 mg). * **Concurrent Propranolol Use:** Propranolol increases rizatriptan plasma concentrations. Patients taking propranolol should use a 5 mg dose, with a maximum total daily dose of 15 mg. ## Contraindications * History of ischemic heart disease (e.g., angina, prior MI, silent ischemia). * Coronary artery vasospasm (Prinzmetal’s angina). * Wolff-Parkinson-White syndrome or arrhythmias associated with accessory conduction pathways. * History of stroke or transient ischemic attack (TIA). * Peripheral vascular disease. * Uncontrolled hypertension. * Administration within 24 hours of another 5-HT1 agonist or ergotamine-type medication. * Concurrent or recent (within 2 weeks) use of monoamine oxidase (MAO) inhibitors. ## Adverse Effects * **Common:** Paresthesia, dizziness, somnolence, fatigue, and sensations of tightness/pressure/heaviness in the chest or throat. * **Serious:** Coronary artery vasospasm, myocardial infarction, arrhythmias, serotonin syndrome (if combined with other serotonergic agents). ## Key Drug Interactions * **MAO Inhibitors:** Risk of severe serotonin syndrome; contraindicated. * **Propranolol:** Increases rizatriptan AUC; dose reduction required. * **SSRIs/SNRIs:** Increased risk of serotonin syndrome; monitor for symptoms (agitation, tremor, hyperreflexia). * **Ergot alkaloids:** Potential for prolonged vasospastic reactions; avoid within 24 hours. ## Monitoring * Monitor cardiovascular status in patients with risk factors during the first administration. * Monitor for signs of serotonin syndrome (e.g., altered mental status, autonomic instability). * Assess for medication overuse headache (MOH) if used >10 days per month. ## Clinical Pearls * **Efficacy:** Effectiveness is generally optimized when taken as early as possible after onset. * **ODT Administration:** ODTs do not require water; do not remove from blister pack until ready to consume. * **Chest Pain:** Patients often report "tightness" or "pressure" in the chest; ensure this is non-cardiac in nature; however, persistent or severe pain requires medical evaluation to rule out cardiac ischemia. * **Uncertainty:** Pediatric dosing guidance varies by institution; always consult local pediatric neurology or pharmacy protocols regarding the use of maximum 24-hour limits. *** *Disclaimer: This information is for educational purposes only. Clinical practice guidelines change frequently. Always consult the latest package insert, official clinical guidelines, or a board-certified clinical pharmacist before prescribing or administering medication.*