What is the recommended dosing for rizatriptan (triptan) in patients with migraine with aura?

Rizatriptan Dosing for Migraine with Aura

For migraine with aura, rizatriptan should be dosed at 5-10 mg orally every two hours as needed, with a maximum daily dose of 30 mg in any 24-hour period. 1

Recommended Dosing Protocol

• The recommended starting dose of rizatriptan is either 5 mg or 10 mg for acute treatment of migraine attacks, including those with aura 1
• The 10 mg dose may provide greater effectiveness than the 5 mg dose but carries a higher risk of adverse reactions 1, 2
• If migraine headache returns after initial treatment, a second dose may be administered 2 hours after the first dose 1
• Do not exceed 30 mg in any 24-hour period 1
• The safety of treating more than four headaches in a 30-day period has not been established 1

Special Dosing Considerations

Patients Taking Propranolol

• For patients taking propranolol, only the 5 mg dose of rizatriptan is recommended 1
• Maximum of 3 doses (15 mg total) in any 24-hour period for adults on propranolol 1

Pediatric Dosing

• For patients 6-17 years: 5 mg for those weighing less than 40 kg (88 lb) 1
• For patients 6-17 years: 10 mg for those weighing 40 kg (88 lb) or more 1
• For pediatric patients on propranolol weighing ≥40 kg: only a single 5 mg dose is recommended 1
• Rizatriptan should not be prescribed to propranolol-treated pediatric patients who weigh less than 40 kg 1

Timing of Administration

• Triptans are most effective when taken early in an attack, when the headache is still mild 3
• However, triptans should not be administered during the aura phase of a migraine attack 3
• Wait until the aura symptoms have resolved and the headache phase has begun before administering rizatriptan 3

Efficacy and Comparative Performance

• Rizatriptan has an efficacy rating of 4 out of 4 (highest effectiveness) for migraine treatment 3
• At 2 hours after dosing, up to 77% of patients taking rizatriptan 10 mg experience pain relief compared with 37% of those taking placebo 2
• Up to 44% of patients are completely pain-free at 2 hours compared with 7% of those taking placebo 2
• Rizatriptan 10 mg provides faster pain relief and higher percentage of patients with absence of pain than naratriptan 2.5 mg or zolmitriptan 2.5 mg 4

Contraindications and Precautions

• Rizatriptan should not be used with ergot-type medications, other triptans, MAOIs, or in patients with CAD 3
• Triptans are contraindicated in patients with:
  • Uncontrolled hypertension 3
  • Basilar or hemiplegic migraine 3
  • Ischemic vascular conditions 5
  • Vasospastic coronary disease 5
  • Significant cardiovascular disease 5

Common Side Effects

• Most common side effects (incidence >2%) are typically transitory (2-3 hours) and mild to moderate 2
• Side effects may include:
  • Tachycardia or bradycardia 3
  • Throat tightness 3
  • Dizziness, somnolence, asthenia/fatigue, and nausea 6
  • Chest pressure or heaviness and paresthesias 5

Clinical Pearls

• If a patient experiences unpleasant sensory disturbances with rizatriptan, trying a different triptan may be beneficial 5
• Patients should try rizatriptan for 2-3 headache episodes before abandoning this therapy 5
• For patients who experience relapse (return of symptoms within 48 hours), rizatriptan can be repeated or combined with fast-acting NSAIDs like naproxen sodium, ibuprofen lysine, or diclofenac potassium 3
• Be aware that repeated treatment does not preclude further relapses and ultimately increases the risk of medication overuse headache 3