When Not to Prescribe Rizatriptan
Do not prescribe rizatriptan to patients with ischemic or vasospastic coronary artery disease, uncontrolled hypertension, history of stroke or TIA, peripheral vascular disease, or hemiplegic/basilar migraine. 1, 2
Absolute Cardiovascular Contraindications
Rizatriptan is contraindicated in the following cardiac conditions due to risk of coronary vasospasm, myocardial infarction, and life-threatening arrhythmias 2:
- Ischemic heart disease or coronary artery disease (CAD) - including prior MI, angina, or documented silent ischemia 1, 2
- Prinzmetal's (vasospastic) angina - rizatriptan can precipitate coronary artery vasospasm even without known CAD 2
- Uncontrolled hypertension - increases risk of cardiovascular events 1, 3, 2
- History of stroke or transient ischemic attack - cerebrovascular events including hemorrhage and stroke have occurred with triptans 2
- Peripheral vascular disease - risk of non-coronary vasospastic reactions including peripheral vascular ischemia 2
- Hemiplegic or basilar migraine - these migraine subtypes carry different stroke risks 1
Drug Interaction Contraindications
Do not combine rizatriptan with the following medications 1, 3:
- Ergot-type medications (ergotamine, dihydroergotamine) - additive vasospastic effects; must wait 24 hours between use 1
- Other triptans - do not use within 24 hours of another triptan 1
- MAO inhibitors - significant drug interaction requiring avoidance 1, 3
- Propranolol - increases rizatriptan levels; if used together, reduce rizatriptan dose to 5 mg maximum 1, 3
High-Risk Patients Requiring Cardiovascular Evaluation
For triptan-naive patients with multiple cardiovascular risk factors, perform cardiovascular evaluation before prescribing rizatriptan 2:
- Increased age (particularly men >40 years, postmenopausal women)
- Diabetes mellitus
- Hypertension
- Current smoking
- Obesity
- Strong family history of CAD
If cardiovascular evaluation is negative, consider administering the first dose in a medically-supervised setting with immediate post-dose ECG 2. For intermittent long-term users with cardiovascular risk factors, periodic cardiovascular evaluation is warranted 2.
Pregnancy and Lactation
Avoid rizatriptan during pregnancy and breastfeeding - safety has not been established in these populations 1. The 2025 American College of Physicians guideline emphasizes discussing adverse effects of pharmacologic treatments during pregnancy and lactation with patients of childbearing potential 1.
Medication Overuse Headache Risk
Do not prescribe rizatriptan for frequent use (≥10 days per month) - triptans carry risk of medication overuse headache when used on 10 or more days monthly for at least 3 months 1. This threshold is lower than NSAIDs (≥15 days/month) 1.
When Rizatriptan Has Failed
If rizatriptan provides inadequate response after appropriate trials, do not continue prescribing it 1. Instead:
- Try a different triptan first - patients may respond to another triptan due to pharmacological differences 1, 4
- If all triptans fail with NSAIDs/acetaminophen, escalate to CGRP antagonists (gepants) or dihydroergotamine 1
- Lasmiditan is reserved for patients who fail all other treatments 1
Clinical Caveats
Discontinue rizatriptan immediately if the following occur 2:
- Life-threatening arrhythmias (ventricular tachycardia/fibrillation)
- Signs of cerebrovascular events
- Symptoms suggesting gastrointestinal ischemia (abdominal pain with bloody diarrhea)
- Evidence of peripheral vascular ischemia or Raynaud's syndrome
Do not use rizatriptan as migraine prophylaxis - it is indicated only for acute treatment 1. If episodic migraines occur frequently, preventive medications should be added rather than increasing triptan frequency 1.