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# Rizatriptan
## Overview
Rizatriptan is a selective serotonin (5-HT1B/1D) receptor agonist used as an abortive treatment for migraine. It is available as oral tablets and orally disintegrating tablets (ODT).
## Primary Indications
Acute treatment of migraine attacks with or without aura in adults and pediatric patients (aged 6 to 17 years). Not indicated for migraine prophylaxis.
## Adult Dosing
* **Initial Dose:** 5 mg or 10 mg at onset of migraine.
* **Repeat Dose:** May repeat dose after 2 hours if necessary.
* **Maximum Dose:** 30 mg in a 24-hour period.
## Pediatric Dosing
* **Ages 6 to 17 years (weight < 40 kg):** 5 mg single dose.
* **Ages 6 to 17 years (weight ≥ 40 kg):** 10 mg single dose.
* **Note:** Efficacy of a second dose in pediatric patients has not been established; generally limited to one dose per 24 hours in clinical practice.
## Dose Adjustments
* **Patients on Propranolol:** Max dose is 5 mg (single dose) up to 3 times in 24 hours (total 15 mg/day).
* **Renal/Hepatic Impairment:** Use with caution; consider 5 mg dose for patients with mild to moderate impairment. Not recommended in severe hepatic impairment.
## Contraindications
* Ischemic heart disease (e.g., history of MI, angina, silent ischemia).
* History of stroke or transient ischemic attack (TIA).
* Peripheral vascular disease or ischemic bowel disease.
* Uncontrolled hypertension.
* Use within 24 hours of another 5-HT1 agonist or ergotamine-derivative.
* Current or recent (within 2 weeks) use of monoamine oxidase (MAO) inhibitors.
## Adverse Effects
* **Common:** Dizziness, somnolence, paresthesia, fatigue, pain or pressure sensations (chest, neck, jaw).
* **Serious:** Coronary artery vasospasm (rare), serotonin syndrome, arrhythmias, seizures, increases in blood pressure.
## Key Drug Interactions
* **SSRIs/SNRIs:** Increased risk of serotonin syndrome; monitor for potential drug-drug interaction.
* **Propranolol:** Increases rizatriptan plasma concentrations significantly by inhibiting metabolism.
* **MAO-A Inhibitors:** Increases systemic exposure; strictly contraindicated within 2 weeks of use.
* **St. John’s Wort:** May increase rizetriptan levels.
## Monitoring
* Monitor cardiovascular status in patients with risk factors for coronary artery disease (e.g., postmenopausal women, males >40, uncontrolled HTN, obesity, diabetes, smoking).
* Assess for chest/throat pressure or tightness upon first dose administration.
## Clinical Pearls
* **Administration:** ODT formulation should be placed on the tongue and allowed to dissolve; no liquid is required. Do not remove from the blister pack until immediately before use.
* **Efficacy:** Effectiveness is significantly improved if taken early during the migraine attack.
* **Medication Overuse:** Frequent use (≥10 days/month) can lead to medication overuse headaches.
* The ODT formulation contains phenylalanine (aspartame), relevant for patients with phenylketonuria (PKU).
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**Educational Disclaimer:** This information is for educational purposes and does not substitute for professional clinical judgment. Always verify current prescribing information, institutional guidelines, and drug monographs via official databases (e.g., Lexicomp, UpToDate) before administering medication.
