Common Side Effects of Rizatriptan and Their Management
The most common side effects of rizatriptan are dizziness, asthenia/fatigue, somnolence, and nausea, which are typically mild, transient (lasting 2-3 hours), and dose-related. 1
Primary Side Effects by Category
Cardiovascular and Pressure Sensations
- Chest pain/tightness/pressure and heaviness occurs in approximately 3% of patients taking the 10 mg dose 2
- Neck/throat/jaw pain, tightness, or pressure affects about 2% of patients 2
- Tachycardia and bradycardia are documented cardiac rhythm disturbances, though specific incidence rates vary 2
- These pressure sensations do not indicate actual cardiac ischemia in most cases but warrant evaluation if severe or persistent 1
Neurological Effects
- Dizziness occurs in 9% of patients on the 10 mg dose versus 5% on placebo 1
- Somnolence affects 8% of patients on 10 mg versus 4% on placebo 1
- Paresthesias (abnormal sensations) occur in 4% of patients on 10 mg 1
- Headache paradoxically occurs in 2% of patients 1
General Systemic Effects
- Asthenia/fatigue affects 7% of patients on 10 mg versus 2% on placebo 1
- Warm sensations are frequently reported 1
Gastrointestinal Effects
- Nausea occurs in 6% of patients on 10 mg versus 4% on placebo 1
- Dry mouth affects 3% of patients 1
- Diarrhea and vomiting are less common but documented 1
Management Strategies
For Sensory Disturbances
- If unpleasant sensory disturbances occur with rizatriptan, switching to a different triptan may be beneficial as individual response varies significantly 3
- Patients should trial the medication for 2-3 headache episodes before abandoning therapy, as response can vary between attacks 3
For Cardiovascular Symptoms
- Reassure patients that chest pressure/heaviness is common and usually benign, but screen for true cardiac contraindications before prescribing 1
- Rizatriptan is absolutely contraindicated in patients with coronary artery disease, ischemic vascular conditions, vasospastic coronary disease, or uncontrolled hypertension 2, 4
- Consider alternative agents such as gepants (ubrogepant, rimegepant) for patients with cardiovascular contraindications 4
For Neurological Side Effects
- Advise patients to avoid driving or operating machinery if experiencing significant dizziness or somnolence 1
- These effects are typically transient, lasting 2-3 hours 5
Dose-Related Considerations
- Side effects are dose-related; the 5 mg dose has lower incidence of adverse effects than the 10 mg dose 1
- Consider starting with 5 mg in patients concerned about tolerability, though efficacy is reduced 1
- Patients taking propranolol should use the 5 mg dose due to drug interactions 2
Critical Safety Warnings
Medication Overuse Headache Prevention
- Limit rizatriptan use to no more than 2 days per week and treat no more than 4 headaches per 30-day period to prevent medication-overuse headache 4
- If patients require acute treatment more than twice weekly, initiate preventive therapy immediately 4
Drug Interactions
- Do not combine with ergot-type medications, MAOIs, other triptans, or SSRIs due to risk of serotonin syndrome and vasospastic reactions 2
- Avoid use within 24 hours of another triptan or ergotamine 2
- Reduce dose to 5 mg when used with propranolol or cimetidine 2
Comparative Tolerability
- Rizatriptan has a higher incidence of adverse events (39%) compared to naratriptan (29%) but similar rates to other triptans 6
- Despite higher side effect rates, rizatriptan provides superior efficacy with faster onset and higher pain-free rates than naratriptan or zolmitriptan 7, 6
When to Discontinue or Switch Therapy
- If side effects are intolerable after 2-3 trials, switch to a different triptan formulation 3
- If partial response with tolerable side effects, consider combining with an NSAID rather than switching 8
- Serious cardiovascular symptoms (severe chest pain, arrhythmias) require immediate discontinuation and cardiac evaluation 1