II. Indications: General
- Migraine Abortive Treatment (age 6 years or older)
- Cluster Headache (off-label except for Sumatriptan)
- Controversial cohorts in whom Triptan use is now thought safe (Cardiovascular Risk Factors)
- Controlled Diabetes Mellitus
- Controlled Hypertension
- Controlled Hyperlipidemia
- Postmenopausal women
- Men over age 40 years
III. Contraindications
- Children age <6 years
- Coronary Artery Disease
- Prinzmetal's Angina
- Uncontrolled Hypertension
- Basilar Artery Migraine
- Familial Hemiplegic Migraine
- Ischemic Cerebrovascular Accident
- Pregnancy
- Concurrent Medication use (absolute contraindications)
- MAO Inhibitor use
- Ergotamine use in prior 24 hours
IV. Mechanism
- Serotonergic 5-HT1 receptor Agonists
- Inhibits sensory dural nerve fiber neuropeptide release
- Intracranial extracerebral artery Vasoconstriction
- Mediated by Triptan direct effect on cerebrovascular Smooth Muscle
V. Precautions
- Screen for cardiovascular disease before use!
- Limit to no more than twice weekly
VI. Medications
- Rizatriptan (Maxalt, Maxalt MLT)
- Standard tablets: 5 mg, 10 mg
- Orally dissolving or disintegrating tablets (ODT): 5 mg, 10 mg
VII. Dosing: Adults (and children weight >40 kg)
- Standard Dosing
- Initial: 5 to 10 mg orally (MLT form is lingual)
- Start at max single dose, 10 mg orally for best efficacy in young adult without contraindications
- Repeat dose in 2 hours
- Maximum: 30 mg in 24 hours
- Initial: 5 to 10 mg orally (MLT form is lingual)
- Dosing for patients taking propranalol
- Limit to 5 mg dose
- Maximum of 3 doses (15 mg total) in 24 hours
VIII. Dosing: Children
- Limited to age 6 years old or older
- Weight >40 kg: Use adult dosing
- Weight <40 kg (and age >6 years)
- Do not use with Propranolol
- Initial dose: 5 mg orally
- May repeat dose in 2 hours
IX. Adverse Effects
- See Triptan Overdose
- Vasospasm
- Generally benign in low risk populations
- Avoid in Coronary Artery Disease, Cerebrovascular Disease, Peripheral Arterial Disease
- Also avoid in hemiplegic Migraine or basilar Migraine
-
Medication Overuse Headaches
- Highest risk with >10 doses per month
- Limit to two doses weekly
X. Safety
- Unknown safety in Lactation
- Pregnancy Category C (most Triptans, but generally avoided in pregnancy)
- See Migraine Medications in Pregnancy
- Not recommended for routine use in pregnancy
- Consult obstetrics before use
- May be considered if Migraines are uncontrolled, debilitating
- If used, Sumatriptan has the longest safety data
- Adverse effects in pregnancy
- Avoid in first trimester (fetal malformations and adverse pregnancy outcomes)
- Risk of uterine atony and peripartum Hemorrhage (but may be considered in debilitating Headache)
- Associated with hyperactivity and emotionality at age 3 in exposed children (AHRQ)
- References
XI. Drug Interactions
- See absolute contraindications above
- Lithium
-
Selective Serotonin Reuptake Inhibitor (SSRI)
- Risk of Serotonin Syndrome when combined with SSRI, SNRI or MAO Inhibitors
-
Propranolol with Rizatriptan
- Requires reducing Rizatriptan dose (see dosing above)
- Combination is contraindicated if weight <40 kg
XII. Efficacy: General
- Most effective oral agents (compared with Imitrex 100 mg PO)
- Rizatriptan (Maxalt) 10 mg orally
- Eletriptan (Relpax) 80 mg orally
- Almotriptan (Axert) 12.5 mg orally (least side effects)
- References
XIII. Management: Overdose or Toxicity
- See Triptan Overdose
Images: Related links to external sites (from Bing)
Related Studies
| rizatriptan (on 12/21/2022 at Medicaid.Gov Survey of pharmacy drug pricing) | ||
| RIZATRIPTAN 10 MG ODT | Generic | $0.74 each |
| RIZATRIPTAN 10 MG TABLET | Generic | $0.45 each |
| RIZATRIPTAN 5 MG ODT | Generic | $0.64 each |
| RIZATRIPTAN 5 MG TABLET | Generic | $0.55 each |