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# Rizatriptan ## Overview Rizatriptan is a selective serotonin 5-HT1B/1D receptor agonist used for the acute treatment of migraine headaches with or without aura. It acts via cranial vessel vasoconstriction and inhibition of pro-inflammatory neuropeptide release. It is available as conventional tablets and orally disintegrating tablets (ODT). ## Primary Indications Acute treatment of migraine attacks in adults and pediatric patients (aged 6 to 17 years). Not indicated for migraine prophylaxis or management of hemiplegic/basilar migraine. ## Adult Dosing * **Initial Dose:** 5 mg or 10 mg at onset of migraine. * **Redosing:** If the headache recurs, a second dose may be taken after at least 2 hours. * **Maximum Dose:** 30 mg in a 24-hour period. * **Note:** If using the 5 mg dose, it is generally preferred if the patient is taking propranolol (due to increased exposure). ## Pediatric Dosing * **Weight < 40 kg:** 5 mg single dose. * **Weight ≥ 40 kg:** 10 mg single dose. * **Maximum Dose:** Only one dose should be administered within a 24-hour period for pediatric patients. Safety/efficacy of a second dose has not been established in this population. ## Dose Adjustments * **Renal Impairment:** No specific dose adjustment recommended, but use with caution in severe impairment. * **Hepatic Impairment:** Mild to moderate impairment: 5 mg dose is recommended. Use is not recommended in severe hepatic impairment. * **Concomitant Propranolol:** Limit dose to 5 mg (max 15 mg/24 hours) as propranolol significantly increases rizatriptan plasma concentrations. ## Contraindications * History of ischemic heart disease, coronary artery vasospasm (Prinzmetal’s angina), or symptoms/findings consistent with ischemic heart disease. * 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. * Administration within 14 days of a Monoamine Oxidase Inhibitor (MAOI). ## Adverse Effects * **Common:** Dizziness, somnolence, paresthesia, and asthenia. * **Cardiac:** Chest pain, tightness, or pressure (usually non-cardiac, but warrants evaluation if persistent). * **Serious:** Serotonin syndrome (especially when combined with SSRIs or SNRIs), coronary vasospasm, myocardial infarction, and arrhythmias. ## Key Drug Interactions * **MAOIs:** Absolute contraindication due to increased risk of toxicity. * **Propranolol:** Increases rizatriptan levels (requires dose reduction). * **SSRIs/SNRIs:** Increases risk of serotonin syndrome; monitor for agitation, tremor, and tachycardia. * **Ergotamines:** Avoid concurrent use (allow 24-hour washout). ## Monitoring * Monitor cardiovascular status, especially in patients with cardiovascular risk factors (consider ECG if treating for the first time in high-risk patients). * Monitor for signs/symptoms of serotonin syndrome. * Monitor pulse and blood pressure following administration. ## Clinical Pearls * **ODT Administration:** The ODT formulation should be placed on the tongue and allowed to dissolve. Do not break the tablet; no liquid is required for administration. * **Medication Overuse Headache (MOH):** Excessive use (typically >10 days per month) of triptans can lead to chronic daily headaches. * **Effectiveness:** Efficacy is highest when taken as soon as possible after symptom onset. * **Uncertainty:** Safety of usage in patients >65 years of age is limited; clinical judgment is required regarding cardiovascular risk profiles. *** *Disclaimer: This information is for educational purposes only. Always consult the most current official product labeling (FDA package insert) or institutional clinical protocols before prescribing or administering any medication.*