What is the lowest approved dose of Maxalt (rizatriptan) for a 15‑year‑old adolescent with migraine and no contraindications (e.g., no cardiovascular disease, uncontrolled hypertension, or monoamine‑oxidase inhibitor use)?

Lowest Approved Dose of Maxalt (Rizatriptan) for a 15-Year-Old

For a 15-year-old adolescent with migraine, the lowest approved dose of Maxalt (rizatriptan) is 5 mg if the patient weighs less than 40 kg (88 lb), or 10 mg if the patient weighs 40 kg (88 lb) or more. 1

Weight-Based Dosing Algorithm

The FDA-approved dosing for rizatriptan in pediatric patients aged 6 to 17 years is strictly weight-based: 1

• Patients weighing <40 kg (88 lb): 5 mg single dose
• Patients weighing ≥40 kg (88 lb): 10 mg single dose

The safety and efficacy of administering more than one dose of rizatriptan within 24 hours in pediatric patients aged 6 to 17 years have not been established. 1 Therefore, only a single dose should be given per day in this age group.

Special Consideration: Concurrent Propranolol Use

If the 15-year-old is taking propranolol for migraine prevention, the dosing must be adjusted: 1

• Patients weighing ≥40 kg on propranolol: Only a single 5 mg dose is recommended (maximum 5 mg in 24 hours)
• Patients weighing <40 kg on propranolol: Rizatriptan should not be prescribed at all 1

This restriction exists because propranolol significantly increases rizatriptan plasma concentrations through drug interaction. 1

Position in Treatment Algorithm

Rizatriptan should not be first-line therapy for adolescent migraine. 2 The evidence-based stepped approach is:

1. First-line: Ibuprofen (appropriate for body weight, typically 400–800 mg) or acetaminophen (1000 mg) 2
2. Second-line (if NSAIDs fail after 2–3 episodes): Triptans, including rizatriptan 2
3. Alternative triptan formulations: Nasal spray formulations of sumatriptan (5–20 mg) or zolmitriptan show the most consistent efficacy in adolescents 2

Evidence Base and Efficacy

Multiple NSAIDs and triptans have been approved for adolescents aged 12–17 years, but the evidence base is complicated by high placebo response rates in pediatric trials. 2 Rizatriptan received FDA approval for patients aged 6–17 years based on clinical trial data, though the therapeutic gain over placebo is modest in this population. 1, 3

Among oral triptans, rizatriptan reaches peak concentration in 60–90 minutes, making it the fastest oral triptan available. 3 However, nasal spray formulations of sumatriptan and zolmitriptan demonstrate superior efficacy in adolescents compared to oral triptans. 2

Critical Frequency Limitation

All acute migraine medications, including rizatriptan, must be limited to no more than 2 days per week (≤10 days per month) to prevent medication-overuse headache. 4 If the adolescent requires acute treatment more than twice weekly, preventive therapy should be initiated immediately rather than increasing the frequency of rizatriptan use. 4

Contraindications in Adolescents

Rizatriptan is contraindicated in adolescents with: 2

• Hemiplegic migraine or basilar migraine
• Known cardiovascular disease or cerebrovascular disease
• Uncontrolled hypertension
• Prior cardiac or cerebral ischemia
• Concurrent or recent (within 24 hours) use of ergotamine derivatives or other triptans

It is reasonable to avoid triptan agents in children with hemiplegic migraine, basilar migraine, known vascular risk factors, or prior cardiac or cerebral ischemia. 2

Common Pitfalls to Avoid

• Do not prescribe more than one dose per 24 hours in adolescents — the safety of multiple doses has not been established in this age group 1
• Do not combine rizatriptan with propranolol in patients <40 kg — this combination is absolutely contraindicated 1
• Do not use rizatriptan as first-line therapy — NSAIDs should be tried first for 2–3 episodes before escalating to triptans 2
• Do not allow frequent use — exceeding 2 days per week creates medication-overuse headache and worsens migraine frequency 4