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# Rizatriptan
## Overview
Rizatriptan is a selective serotonin (5-HT1B/1D) receptor agonist used for the acute treatment of migraine. It induces cranial vessel constriction and inhibits the release of pro-inflammatory neuropeptides. It is available as an oral tablet and an orally disintegrating tablet (ODT).
## Primary Indications
Acute treatment of migraine, with or without aura, in adults and pediatric patients (6–17 years).
## Adult Dosing
* **Standard dose:** 5 mg or 10 mg orally at the onset of migraine.
* **Dosing interval:** If migraine recurs or there is no response, a second dose may be taken after at least 2 hours.
* **Maximum daily dose:** 30 mg in a 24-hour period.
## Pediatric Dosing (6–17 years)
* **Weight <40 kg:** 5 mg single dose.
* **Weight ≥40 kg:** 10 mg single dose.
* **Maximum frequency:** Do not repeat dose within 24 hours. Safety and efficacy of a second dose have not been established in the pediatric population.
## Dose Adjustments
* **Hepatic/Renal Impairment:** Generally not required, but consider 5 mg dose if comorbid conditions are present.
* **Propranolol use:** Propranolol increases rizatriptan plasma concentrations. Patients taking propranolol should use the 5 mg dose, limited to a maximum of 15 mg per 24 hours.
## Contraindications
* History of ischemic heart disease (e.g., angina, 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.
* Ischemic bowel disease.
* Uncontrolled hypertension.
* Administration within 24 hours of another 5-HT1 agonist or ergotamine-type medication.
* Use within 2 weeks of discontinuing a monoamine oxidase inhibitor (MAOI).
## Adverse Effects
* **Common:** Dizziness, somnolence, paresthesia, fatigue, flushing, and xerostomia (dry mouth).
* **Serious:** Coronary vasospasm, myocardial infarction, arrhythmias, stroke, and serotonin syndrome (especially when combined with SSRIs/SNRIs).
## Key Drug Interactions
* **MAOIs:** Potential for significant increases in rizatriptan blood levels; contraindicated.
* **Propranolol:** Increases rizatriptan systemic exposure (requires dose capping).
* **Serotoninergic agents (SSRIs, SNRIs, TCAs):** Risk of serotonin syndrome.
* **Ergot-containing drugs:** Additive vasospastic effects; separate dosing by at least 24 hours.
## Monitoring
* Monitor blood pressure during initial use in patients with cardiovascular risk factors.
* Assess for chest pain, tightness, or pressure (cardiac evaluation may be warranted for high-risk patients).
* Monitor for signs/symptoms of serotonin syndrome if used with other serotonergic medications.
## Clinical Pearls
* **ODT formulation:** The blister pack should be dry; peel with dry hands and place on the tongue to dissolve without water.
* **Medication Overuse Headache (MOH):** Excessive use (typically >10 days per month) of triptans can lead to chronic daily headache.
* **Efficacy:** Effectiveness is significantly improved if taken at the earliest onset of migraine symptoms.
* **Cardiovascular screening:** For patients with multiple risk factors (e.g., postmenopausal women, males >40, smokers, diabetics), assess cardiovascular status before administration of the first dose.
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**Educational Disclaimer:** This summary is for informational purposes and does not replace professional clinical judgment. Always verify current prescribing information, institutional guidelines, and drug-specific package inserts before administration.
