What are the contraindications to Maxalt (rizatriptan)?

Contraindications to Maxalt (Rizatriptan)

Maxalt (rizatriptan) is absolutely contraindicated in patients with ischemic heart disease, coronary artery vasospasm, history of stroke or TIA, peripheral vascular disease, ischemic bowel disease, uncontrolled hypertension, hemiplegic or basilar migraine, recent use of other triptans or ergot medications, and concurrent use or recent discontinuation of MAO-A inhibitors. 1

Cardiovascular Contraindications

Rizatriptan should not be used in patients with:

• Ischemic coronary artery disease (including angina pectoris, history of myocardial infarction, or documented silent ischemia) 1
• Coronary artery vasospasm including Prinzmetal's angina 1
• Peripheral vascular disease (PVD) 1
• Significant underlying cardiovascular disease 2
• Uncontrolled hypertension 2, 1

Cerebrovascular Contraindications

• History of stroke or transient ischemic attack (TIA) 1
• Hemiplegic or basilar migraine 1

Gastrointestinal Contraindications

• Ischemic bowel disease 1

Medication Interaction Contraindications

• Recent use (within 24 hours) of another 5-HT1 agonist 1
• Recent use (within 24 hours) of ergotamine-containing medications or ergot-type medications (such as dihydroergotamine or methysergide) 1
• Concurrent administration or recent discontinuation (within 2 weeks) of a MAO-A inhibitor 1
• Use with propranolol requires dose adjustment (not a contraindication but an important precaution) 1

Other Contraindications

• Hypersensitivity to rizatriptan (angioedema and anaphylaxis have been reported) 1

Important Clinical Considerations

Risk of Vasospastic Reactions

Triptans as a class can cause non-coronary vasospastic reactions, including:

• Peripheral vascular ischemia
• Gastrointestinal vascular ischemia and infarction
• Splenic infarction
• Raynaud's syndrome 1

Serotonin Syndrome Risk

Serotonin syndrome may occur with triptans, particularly during co-administration with:

• Selective serotonin reuptake inhibitors (SSRIs)
• Serotonin norepinephrine reuptake inhibitors (SNRIs)
• Tricyclic antidepressants (TCAs)
• MAO inhibitors 1

Blood Pressure Effects

Significant elevation in blood pressure, including hypertensive crisis with acute impairment of organ systems, has been reported on rare occasions in patients with and without a history of hypertension receiving triptans like rizatriptan 1.

Medication Overuse Headache

Overuse of acute migraine drugs (including triptans) for 10 or more days per month may lead to exacerbation of headache (medication overuse headache) 1. This is an important consideration when prescribing Maxalt.

Clinical Pitfalls to Avoid

1. Always screen for cardiovascular risk factors before prescribing rizatriptan
2. Never use rizatriptan within 24 hours of other triptans or ergot derivatives
3. Be cautious when prescribing to patients on SSRIs or SNRIs due to serotonin syndrome risk
4. Monitor for signs of medication overuse headache in patients using rizatriptan frequently
5. Avoid use in pregnancy unless the potential benefit justifies the potential risk to the fetus

Rizatriptan is generally well-tolerated when used appropriately, with the most common side effects being dizziness, drowsiness, and asthenia/fatigue, which are typically short-lasting and of mild to moderate severity 3.