What is the recommended treatment for a patient with a history of cardiovascular disease, hypertension, and impaired renal or hepatic function experiencing a migraine attack, considering Maxalt (rizatriptan) as a potential option?

Maxalt (Rizatriptan) in Patients with Cardiovascular Disease, Hypertension, and Organ Impairment

Rizatriptan (Maxalt) is contraindicated in patients with cardiovascular disease and should not be used in this population. 1

Absolute Contraindications for Rizatriptan

• Coronary artery disease (CAD) is an absolute contraindication to rizatriptan use, including patients with history of myocardial infarction, angina, or any ischemic cardiac disease 1
• Uncontrolled hypertension represents a contraindication to all triptans, including rizatriptan 1
• Rizatriptan should not be used in patients with hemiplegic or basilar migraine 1

Dosing Adjustments for Organ Impairment

For patients with renal impairment:

• Mild to moderate renal impairment (creatinine clearance 10-60 mL/min/1.73 m²) requires no dose adjustment, as AUC is not significantly different from normal renal function 2
• Hemodialysis patients (creatinine clearance <2 mL/min/1.73 m²) show 44% greater AUC and should use a reduced dose of 5 mg, with maximum of 5 mg in 24 hours 2

For patients with hepatic impairment:

• Mild hepatic insufficiency requires no dose adjustment 2
• Moderate hepatic impairment results in approximately 30% greater plasma concentrations, warranting use of the 5 mg dose with maximum of 5 mg in 24 hours 2

Alternative Treatment Options for This Patient Population

First-line alternatives for patients with cardiovascular contraindications:

• NSAIDs remain first-line therapy for mild to moderate migraine in patients with cardiovascular disease, specifically naproxen sodium 500-825 mg or ibuprofen 400-800 mg 1, 3
• Limit NSAID use to no more than 2 days per week to prevent medication-overuse headache 1, 3

Second-line alternatives when NSAIDs fail:

• CGRP antagonists (gepants) such as ubrogepant 50-100 mg or rimegepant are the preferred alternative, as they have no vasoconstrictor activity and are safe in cardiovascular disease 3
• Lasmiditan (Reyvow) 50-200 mg is a 5-HT1F receptor agonist without vasoconstrictor activity, making it safe for patients with cardiovascular disease, though patients must not drive for at least 8 hours after use due to CNS effects 3

For severe attacks requiring parenteral therapy:

• IV metoclopramide 10 mg plus IV ketorolac 30 mg provides effective combination therapy without cardiovascular risk 3, 4
• Metoclopramide provides direct analgesic effects through central dopamine receptor antagonism beyond its antiemetic properties 3, 4
• Ketorolac should be used cautiously in renal impairment or history of GI bleeding 3

Critical Drug Interactions with Rizatriptan

If rizatriptan were to be considered (which it should not be in this patient):

• Propranolol increases rizatriptan AUC by 70%, requiring dose reduction to 5 mg with maximum of 10 mg in 24 hours 1, 2
• MAO inhibitors (both selective MAO-A and nonselective) dramatically increase rizatriptan concentrations, with moclobemide increasing AUC by 119% and active metabolite by >400% 2
• Rizatriptan should not be used within 24 hours of ergot-type medications or other triptans 1

Preventive Therapy Consideration

This patient should be evaluated for preventive therapy if:

• Experiencing ≥2 migraine attacks per month with disability lasting ≥3 days 1, 5
• Using acute medications more than twice per week 1, 5
• Acute treatments are contraindicated or have failed 1, 5

First-line preventive options considering comorbidities:

• Beta-blockers (propranolol 80-240 mg/day or timolol 20-30 mg/day) address both migraine prevention and hypertension 1, 5
• Candesartan is particularly useful for patients with comorbid hypertension 5
• Avoid valproate/divalproex in women of childbearing potential due to teratogenic effects 1, 5

Common Pitfall to Avoid

Do not prescribe triptans to patients with any cardiovascular disease, uncontrolled hypertension, or cerebrovascular disease, as these medications cause vasoconstriction and can precipitate myocardial infarction, ventricular arrhythmias, or stroke 1. Instead, transition immediately to gepants (ubrogepant or rimegepant) or lasmiditan as migraine-specific alternatives with proven safety in cardiovascular disease 3.