Maxalt (Rizatriptan) and Alternative Migraine Treatments
Primary Recommendation
Rizatriptan 10 mg is highly effective for acute moderate-to-severe migraine attacks, providing pain relief in up to 77% of patients within 2 hours, but must be limited to no more than 2 days per week to prevent medication-overuse headache, and is absolutely contraindicated in patients with cardiovascular disease. 1
Rizatriptan Dosing and Administration
Standard Dosing Protocol
- Take 5-10 mg orally at migraine onset when headache is still mild for maximum effectiveness 2
- If headache returns or provides only partial relief, a second dose may be taken after 2 hours 2
- Maximum daily dose: 30 mg per 24 hours 2
- Critical frequency limitation: Use no more than 2 days per week to prevent medication-overuse headache 1
Formulation Advantages
- Rizatriptan is available as an orally disintegrating wafer (Maxalt MLT) that dissolves rapidly without liquids, offering convenient administration 3
- The 10 mg dose reaches peak concentration in 60-90 minutes, making it the fastest oral triptan available 2
Absolute Cardiovascular Contraindications
Rizatriptan is contraindicated in patients with: 2, 1
- Coronary artery disease (CAD) or history of myocardial infarction
- Ischemic vascular conditions or vasospastic coronary disease
- Uncontrolled hypertension
- History of stroke or transient ischemic attack
- Peripheral vascular disease
- Hemiplegic or basilar migraine
Drug Interactions Requiring Avoidance
- Do not use within 24 hours of other triptans or ergot-type medications 2
- Avoid concurrent use with MAOIs or within 2 weeks of MAOI discontinuation 2
- Reduce dose to 5 mg when taking propranolol or cimetidine 2
Alternative Triptan Options When Rizatriptan Fails
If rizatriptan fails after 2-3 migraine episodes, try a different triptan, as failure of one does not predict failure of others. 2
Alternative Oral Triptans (Ranked by Speed and Efficacy)
Eletriptan 40 mg:
- More effective with fewer adverse reactions than sumatriptan 2
- Contraindicated with potent CYP3A4 inhibitors (ketoconazole, clarithromycin, ritonavir) within 72 hours 4
Zolmitriptan 2.5-5 mg:
Naratriptan 1.0-2.5 mg:
- Longest half-life among triptans, which may decrease recurrent headaches 2
- Maximum 5 mg per day 2
- Lower efficacy than rizatriptan but better tolerability profile 5
Sumatriptan 50-100 mg:
- Established efficacy but slower onset than rizatriptan 2
- Available in multiple formulations (oral, subcutaneous, intranasal) 2
Non-Oral Triptan Routes for Severe Attacks
Subcutaneous sumatriptan 6 mg:
- Highest efficacy of all triptan formulations, providing pain relief in 70-82% of patients within 15 minutes 2
- Ideal for patients with rapid progression to peak intensity or significant nausea/vomiting 2
- Maximum 12 mg per 24 hours 2
Intranasal sumatriptan 5-20 mg:
First-Line Alternatives for Patients with Cardiovascular Contraindications
CGRP Antagonists (Gepants) - Preferred Alternative
Ubrogepant or rimegepant are the primary alternatives when triptans are contraindicated due to cardiovascular disease, as they have no vasoconstriction. 1, 6
- Gepants are safe for patients with CAD, uncontrolled hypertension, or cerebrovascular disease 1
- Must still be limited to no more than 2 days per week to prevent medication-overuse headache 1
Ditans (Lasmiditan) - Second-Line Alternative
Lasmiditan 50-200 mg is a 5-HT1F receptor agonist without vasoconstrictor activity, making it safe for cardiovascular patients. 6
Critical safety warning: Patients must not drive or operate machinery for at least 8 hours after taking lasmiditan due to CNS effects (dizziness, vertigo, somnolence) 6
Non-Triptan Acute Treatment Options
NSAIDs - First-Line for Mild-to-Moderate Migraine
For mild-to-moderate attacks, start with NSAIDs before escalating to triptans: 6
- Naproxen sodium 500-825 mg at onset, can repeat every 2-6 hours (maximum 1.5 g/day) 2, 6
- Ibuprofen 400-800 mg every 2 hours (maximum 200 mg/day) 6
- Aspirin 1000 mg at onset 6
Combination therapy (aspirin + acetaminophen + caffeine) is more effective than single agents for moderate attacks. 6
Antiemetics with Analgesic Properties
Metoclopramide 10 mg IV or oral:
- Provides direct analgesic effects through central dopamine receptor antagonism, independent of antiemetic properties 6
- Enhances absorption of co-administered medications by overcoming gastric stasis 6
- Contraindicated in pheochromocytoma, seizure disorder, GI bleeding, and GI obstruction 2
Prochlorperazine 10 mg IV or 25 mg oral:
- Comparable efficacy to metoclopramide with potentially fewer side effects 6
- Contraindicated in CNS depression and use of adrenergic blockers 2
Dihydroergotamine (DHE)
Intranasal or IV DHE has good evidence for efficacy as monotherapy for acute migraine attacks. 6
- Intranasal: 0.5 mg spray in each nostril, repeat after 15 minutes (maximum 2 mg/day) 2
- IV: 0.5-1.0 mg, can repeat every hour (maximum 2 mg IV/day, 3 mg IM/day) 2
- Contraindicated with concurrent triptan use, CAD, uncontrolled hypertension, pregnancy, and within 24 hours of other ergot medications 2
Optimal Combination Therapy Strategies
For Moderate-to-Severe Attacks
Triptan + NSAID combination is superior to either agent alone and represents the strongest recommendation from current guidelines. 6
Recommended combinations:
- Rizatriptan 10 mg + naproxen sodium 500 mg 6
- Sumatriptan 50-100 mg + naproxen sodium 500 mg (130 more patients per 1000 achieve sustained pain relief at 48 hours compared to monotherapy) 6
For Emergency/IV Treatment
Metoclopramide 10 mg IV + ketorolac 30 mg IV provides rapid pain relief while minimizing side effects and rebound headache risk. 6
- Ketorolac has rapid onset with approximately 6 hours duration 6
- Use caution in patients with renal impairment, history of GI bleeding, or heart disease 6
Medications to Absolutely Avoid
Never use opioids (hydromorphone, meperidine) or butalbital-containing compounds for migraine treatment. 6
- These medications have questionable efficacy for migraine 6
- Lead to dependency, rebound headaches, and eventual loss of efficacy 6
- Should only be reserved for cases where all other medications are contraindicated 6
Prevention of Medication-Overuse Headache
Critical Frequency Limits
All acute migraine medications must be limited to no more than 2 days per week (10 days per month) to prevent medication-overuse headache. 1, 6
- Medication-overuse headache can lead to daily headaches and increasing headache frequency 1
- If patients require acute treatment more than twice weekly, preventive therapy should be initiated immediately 1
When to Initiate Preventive Therapy
Preventive therapy is indicated for: 6
- Two or more attacks per month producing disability lasting 3+ days
- Use of abortive medication more than twice per week
- Contraindication to or failure of acute treatments
- Presence of uncommon migraine conditions (hemiplegic, basilar)
First-line preventive options include: 6
- Propranolol 80-240 mg/day
- Topiramate (dose titrated)
- Amitriptyline 30-150 mg/day (especially for mixed migraine and tension-type headache)
- CGRP monoclonal antibodies (when oral preventives fail)
Common Clinical Pitfalls to Avoid
Do not abandon triptan therapy after a single failed attempt - try a different triptan, as failure of one does not predict failure of others 2
Do not allow patients to increase frequency of acute medication use in response to treatment failure - this creates a vicious cycle of medication-overuse headache; instead transition to preventive therapy 6
Do not use triptans and ergot medications within 24 hours of each other due to additive vasoconstrictive effects 2
Do not prescribe triptans without screening for cardiovascular risk factors - perform cardiac evaluation if risk factors present before initiating therapy 1
Do not use metoclopramide or prochlorperazine chronically - limit to twice weekly to prevent medication-overuse headache and tardive dyskinesia risk 6