Can a patient with chronic arthritis, potential migraines, and hypertension, taking metoprolol (beta-blocker), safely take rizatriptan (serotonin receptor agonist) for migraine relief?

Can Rizatriptan Be Taken With Metoprolol?

Yes, rizatriptan can be safely taken with metoprolol without dose adjustment, as metoprolol does not significantly alter rizatriptan pharmacokinetics. 1

Key Pharmacokinetic Evidence

• Metoprolol (100 mg twice daily for 7 days) does not significantly alter the pharmacokinetics of rizatriptan 10 mg, based on a double-blind, placebo-controlled, randomized crossover study in healthy subjects 1
• This contrasts sharply with propranolol, which increases rizatriptan AUC by approximately 67% and Cmax by approximately 75%, requiring dose reduction to 5 mg 1
• The lack of interaction with metoprolol is explained by the fact that metoprolol does not inhibit monoamine oxidase-A (MAO-A), the primary enzyme responsible for rizatriptan metabolism 1

Clinical Recommendations for Your Patient

For patients taking metoprolol, use the standard rizatriptan 10 mg dose for acute migraine treatment. 1

• The 2024 VA/DoD guidelines strongly recommend rizatriptan (along with other triptans) for short-term treatment of migraine 2
• The 2025 American College of Physicians guidelines recommend combination therapy of rizatriptan plus naproxen 500 mg for superior efficacy compared to either agent alone 2, 3
• This combination results in 300 more patients per 1000 achieving pain freedom at 2 hours compared to NSAID monotherapy 3

Critical Frequency Limitation

Limit all acute migraine medications to no more than 2 days per week (10 days per month) to prevent medication-overuse headache. 4, 5

• Medication-overuse headache can paradoxically increase headache frequency and lead to daily headaches 4, 5
• If the patient requires acute treatment more than twice weekly, initiate preventive therapy immediately rather than continuing frequent acute medication use 4

Cardiovascular Considerations

• Metoprolol is an appropriate beta-blocker for this patient with hypertension, as it is included in guideline-directed management and therapy (GDMT) for blood pressure control 2
• One study showed metoprolol may actually reduce apnea-hypopnea index (AHI) in hypertensive patients with obstructive sleep apnea, though this is not directly relevant to migraine treatment 2
• Rizatriptan is contraindicated in patients with uncontrolled hypertension, coronary artery disease, or cerebrovascular disease 6
• Ensure the patient's hypertension is controlled on metoprolol before prescribing rizatriptan 6

Optimal Treatment Strategy

Consider rizatriptan 10 mg PLUS naproxen 500 mg as first-line combination therapy for moderate to severe migraine attacks. 2, 3

• This combination is superior to either agent alone with high-certainty evidence 2
• Take medication early in the attack while pain is still mild for maximum effectiveness 5, 3
• The combination results in 130 more patients per 1000 achieving sustained pain relief at 48 hours compared to triptan monotherapy 2

Common Pitfall to Avoid

Do not confuse metoprolol with propranolol—only propranolol requires rizatriptan dose reduction to 5 mg. 1

• Propranolol inhibits MAO-A metabolism of rizatriptan, but metoprolol does not 1
• No untoward adverse experiences attributable to the combination of rizatriptan with metoprolol were observed in clinical trials 1
• The patient can safely use the full 10 mg dose of rizatriptan while taking metoprolol 1