Pharm

Rizatriptan

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Rizatriptan, Maxalt

  • See Also
  1. Triptan
  2. Migraine Abortive Treatment
  3. Triptan Overdose
  • Indications
  • General
  1. Migraine Abortive Treatment (age 6 years or older)
  2. Cluster Headache (off-label except for Sumatriptan)
  3. Controversial cohorts in whom Triptan use is now thought safe (Cardiovascular Risk Factors)
    1. Controlled Diabetes Mellitus
    2. Controlled Hypertension
    3. Controlled Hyperlipidemia
    4. Postmenopausal women
    5. Men over age 40 years
  • Contraindications
  1. Children age <6 years
  2. Coronary Artery Disease
  3. Prinzmetal's Angina
  4. Uncontrolled Hypertension
  5. Basilar Artery Migraine
  6. Familial Hemiplegic Migraine
  7. Ischemic Cerebrovascular Accident
  8. Pregnancy
  9. Concurrent Medication use (absolute contraindications)
    1. MAO Inhibitor use
    2. Ergotamine use in prior 24 hours
  • Mechanism
  1. Serotonergic 5-HT1 receptor Agonists
  2. Inhibits sensory dural nerve fiber neuropeptide release
  3. Intracranial extracerebral artery Vasoconstriction
    1. Mediated by Triptan direct effect on cerebrovascular Smooth Muscle
  • Precautions
  1. Screen for cardiovascular disease before use!
  2. Limit to no more than twice weekly
  • Medications
  1. Rizatriptan (Maxalt, Maxalt MLT)
    1. Standard tablets: 5 mg, 10 mg
    2. Orally dissolving or disintegrating tablets (ODT): 5 mg, 10 mg
  • Dosing
  • Adults (and children weight >40 kg)
  1. Standard Dosing
    1. Initial: 5 to 10 mg orally (MLT form is lingual)
      1. Start at max single dose, 10 mg orally for best efficacy in young adult without contraindications
    2. Repeat dose in 2 hours
    3. Maximum: 30 mg in 24 hours
  2. Dosing for patients taking propranalol
    1. Limit to 5 mg dose
    2. Maximum of 3 doses (15 mg total) in 24 hours
  • Dosing
  • Children
  1. Limited to age 6 years old or older
  2. Weight >40 kg: Use adult dosing
  3. Weight <40 kg (and age >6 years)
    1. Do not use with Propranolol
    2. Initial dose: 5 mg orally
    3. May repeat dose in 2 hours
  • Adverse Effects
  1. See Triptan Overdose
  2. Vasospasm
    1. Generally benign in low risk populations
    2. Avoid in Coronary Artery Disease, Cerebrovascular Disease, Peripheral Arterial Disease
    3. Also avoid in hemiplegic Migraine or basilar Migraine
  3. Medication Overuse Headaches
    1. Highest risk with >10 doses per month
    2. Limit to two doses weekly
  • Safety
  1. Unknown safety in Lactation
  2. Pregnancy Category C (most Triptans, but generally avoided in pregnancy)
    1. See Migraine Medications in Pregnancy
    2. Not recommended for routine use in pregnancy
    3. Consult obstetrics before use
    4. May be considered if Migraines are uncontrolled, debilitating
      1. If used, Sumatriptan has the longest safety data
    5. Adverse effects in pregnancy
      1. Avoid in first trimester (fetal malformations and adverse pregnancy outcomes)
      2. Risk of uterine atony and peripartum Hemorrhage (but may be considered in debilitating Headache)
      3. Associated with hyperactivity and emotionality at age 3 in exposed children (AHRQ)
    6. References
      1. Nezvalova-Henriksen (2010) Headache 50(4): 563-75 +PMID: 20132339 [PubMed]
  • Drug Interactions
  1. See absolute contraindications above
    1. Ergotamine
    2. MAO Inhibitors
  2. Lithium
  3. Selective Serotonin Reuptake Inhibitor (SSRI)
    1. Risk of Serotonin Syndrome when combined with SSRI, SNRI or MAO Inhibitors
  4. Propranolol with Rizatriptan
    1. Requires reducing Rizatriptan dose (see dosing above)
    2. Combination is contraindicated if weight <40 kg
  1. Most effective oral agents (compared with Imitrex 100 mg PO)
    1. Rizatriptan (Maxalt) 10 mg orally
    2. Eletriptan (Relpax) 80 mg orally
    3. Almotriptan (Axert) 12.5 mg orally (least side effects)
  2. References
    1. Ferrari (2001) Lancet 358:1668-75 [PubMed]
  1. See Triptan Overdose
  • Resources
  1. Rizatriptan (DailyMed)
    1. https://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=35f26d3c-268b-4114-9b5b-1c2e0b9ddfd5
  2. Triptans (StatPearls)
    1. https://www.ncbi.nlm.nih.gov/books/NBK554507/
  3. Where do Triptans act in the treatment of Migraine? (PMC)
    1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1850935/
  • References
  1. Jamieson (2002) Am J Med 112:138 [PubMed]
  2. Ahn (2005) Pain 115(1-2):1-4 +PMID: 15836963 [PubMed]