What is the recommended dosage and usage of Rizatriptan (Maxalt) for the acute treatment of migraine headaches in adults?

Rizatriptan Dosing and Administration for Acute Migraine

For adults, start with rizatriptan 10 mg orally at migraine onset, which provides superior efficacy compared to the 5 mg dose, with up to 71% achieving pain relief and 42% achieving complete pain freedom at 2 hours. 1, 2

Standard Adult Dosing

• The recommended starting dose is either 5 mg or 10 mg, but the 10 mg dose is preferred as it provides greater efficacy with faster onset of action, showing pain relief as early as 30 minutes after dosing. 1, 2
• If the migraine returns after initial response, a second dose may be administered 2 hours after the first dose, with a maximum daily dose of 30 mg in any 24-hour period. 1
• The 10 mg dose achieves pain relief in up to 77% of patients at 2 hours compared to 37% with placebo, and complete pain freedom in up to 44% compared to 7% with placebo. 3

Pediatric Dosing (Ages 6-17 Years)

• Dosing is weight-based: 5 mg for patients weighing less than 40 kg (88 lb), and 10 mg for patients weighing 40 kg or more. 1
• The safety and efficacy of treating with more than one dose within 24 hours in pediatric patients has not been established. 1

Critical Dosage Adjustment for Propranolol Users

• In adults taking propranolol, use only the 5 mg dose, up to a maximum of 3 doses in 24 hours (15 mg total). 1
• For pediatric patients ≥40 kg taking propranolol, use only a single 5 mg dose (maximum 5 mg in 24 hours). 1
• Rizatriptan should not be prescribed to propranolol-treated pediatric patients weighing less than 40 kg. 1

Combination Therapy for Enhanced Efficacy

• Add an NSAID (naproxen 500 mg, ibuprofen 400-800 mg) to rizatriptan for superior efficacy, as combination therapy is more effective than either agent alone. 4, 5
• If rizatriptan alone provides insufficient relief, add an NSAID rather than increasing triptan dose or frequency. 6

Managing Inadequate Response

• Patients should try rizatriptan for 2-3 separate headache episodes before determining effectiveness, as response can vary between attacks. 5, 2
• If inadequate response occurs after appropriate dosing for 2-3 attacks, switch to another triptan (sumatriptan, eletriptan, zolmitriptan, naratriptan, or almotriptan), as failure of one triptan does not predict failure of others. 4, 5
• Rizatriptan 10 mg has been shown to be more effective than naratriptan 2.5 mg or zolmitriptan 2.5 mg at producing pain-free status at 2 hours. 7

Managing Headache Recurrence

• For patients experiencing headache recurrence after initial benefit, a second dose provides relief in 82% of patients with the 10 mg dose compared to 44% with placebo. 2
• Complete relief of recurrent headache is obtained in 49% with rizatriptan 10 mg compared to 15% with placebo. 2

Critical Frequency Limitation to Prevent Medication-Overuse Headache

• Limit rizatriptan use to no more than 2 days per week (10 days per month) to prevent medication-overuse headache, which can paradoxically increase headache frequency and lead to daily headaches. 4, 5
• The safety of treating more than four headaches in a 30-day period has not been established. 1
• If the patient requires acute treatment more than twice weekly, initiate preventive therapy immediately. 4

Timing and Administration

• Administer rizatriptan early in the headache phase when pain is still mild for optimal effectiveness and maximum benefit. 4, 6
• Rizatriptan reaches peak concentration in 60-90 minutes, making it the fastest oral triptan available. 4

Contraindications and Safety Considerations

• Rizatriptan is contraindicated in patients with ischemic heart disease, previous myocardial infarction, uncontrolled hypertension, hemiplegic or basilar migraine, or significant cardiovascular disease. 4, 6
• Do not use rizatriptan within 24 hours of another triptan or ergotamine-containing medications due to additive vasoconstrictive effects. 4, 6
• Rizatriptan is contraindicated with concurrent MAOI use. 6

Tolerability Profile

• Rizatriptan is generally well tolerated, with the most common adverse events being dizziness, somnolence, asthenia/fatigue, and nausea, which are typically mild, transient (2-3 hours), and dose-related. 3, 2, 7
• There is no increase in adverse event incidence after using up to three doses within 24 hours. 2
• Long-term studies treating more than 46,000 attacks showed consistent efficacy without evidence of tachyphylaxis. 8