Maxalt

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Maxalt is a prescription-only medicine containing rizatriptan, used to treat acute migraine attacks with or without aura in adults.

It belongs to the triptan class of medicines, which are considered the gold standard for acute migraine treatment when simple analgesics such as paracetamol and ibuprofen are insufficient.

Maxalt is available as conventional tablets (5 mg and 10 mg) and as orodispersible wafers (Maxalt Melt), which dissolve on the tongue without water.

The orodispersible formulation is particularly useful during migraine attacks when nausea or vomiting makes swallowing tablets difficult.

Maxalt is manufactured by Merck Sharp and Dohme (MSD) and is also available as generic rizatriptan.

Migraine is one of the most common neurological conditions in the United Kingdom, affecting approximately 1 in 7 adults.

It is the leading cause of disability in people under 50, according to the Global Burden of Disease study.

A migraine attack typically involves a moderate to severe throbbing headache, often on one side of the head, accompanied by nausea, vomiting, and heightened sensitivity to light (photophobia) and sound (phonophobia).

Attacks usually last between 4 and 72 hours and can significantly impair daily activities, work productivity, and quality of life.

This page provides a comprehensive clinical overview of Maxalt, covering how it works, dosage guidance, potential side effects, safety warnings, and how to obtain a prescription in the United Kingdom.

Important safety information about Maxalt

Before reading further, note these essential safety points.

• Maxalt is a prescription-only medicine for the acute treatment of migraine. It must not be used as a preventive treatment.
• Do not take more than two doses (20 mg) in any 24-hour period.
• If the first dose does not relieve your migraine, do not take a second dose for the same attack.
• Maxalt must not be used within 24 hours of another triptan or an ergotamine-containing medicine.
• Tell your prescriber about all medicines you take, particularly antidepressants (SSRIs, SNRIs), propranolol, and MAO inhibitors.

Understanding migraine

Migraine is a complex neurological disorder involving abnormal activation of the trigeminovascular system.

The current understanding is that migraine begins with cortical spreading depression (a wave of neuronal excitation followed by inhibition that spreads across the cerebral cortex), which activates trigeminal nerve fibres surrounding the meningeal blood vessels.

These nerve fibres release vasoactive neuropeptides, including calcitonin gene-related peptide (CGRP), substance P, and neurokinin A, which cause vasodilation, plasma protein extravasation, and neurogenic inflammation around the meningeal vessels.

This process stimulates pain-sensitive structures, producing the characteristic headache.

Migraine may present with or without aura.

Aura, which affects about one-third of migraine sufferers, typically precedes the headache by 5 to 60 minutes and involves visual disturbances (flashing lights, zigzag lines, blind spots), sensory symptoms (tingling or numbness in the face or hand), or, less commonly, speech disturbance.

Migraine without aura is more common and involves the headache and associated symptoms without preceding neurological features.

The management of migraine involves both acute treatment (to relieve individual attacks) and preventive treatment (to reduce attack frequency and severity).

NICE clinical guideline CG150 recommends a stepped approach to acute treatment: starting with a combination of a simple analgesic (paracetamol or an NSAID such as ibuprofen or aspirin) and an anti-emetic (such as metoclopramide or domperidone), progressing to a triptan if initial treatment is inadequate.

How Maxalt works: mechanism of action

Rizatriptan is a selective agonist of serotonin 5-HT1B and 5-HT1D receptors. These receptors are located on cranial blood vessels and on trigeminal sensory nerve terminals.

Activation of 5-HT1B receptors on meningeal blood vessels causes vasoconstriction, reversing the pathological vasodilation that occurs during a migraine attack.

Activation of 5-HT1D receptors on presynaptic trigeminal nerve terminals inhibits the release of pro-inflammatory and vasodilatory neuropeptides (CGRP, substance P), reducing neurogenic inflammation and blocking pain signal transmission to the trigeminal nucleus caudalis in the brainstem.

Additionally, rizatriptan may have central analgesic effects by inhibiting pain signal processing in the trigeminal nucleus caudalis.

The combined peripheral vasoconstrictor and anti-inflammatory actions, together with central pain modulation, account for the rapid and effective relief of migraine headache and associated symptoms (nausea, photophobia, phonophobia) that triptans provide.

Rizatriptan is rapidly absorbed after oral administration, with peak plasma concentrations reached in approximately 1 to 1.5 hours. The elimination half-life is approximately 2 to 3 hours.

It is primarily metabolised by monoamine oxidase A (MAO-A) in the liver.

The orodispersible wafer has a slightly slower absorption profile than the conventional tablet due to pre-gastric absorption, but clinical efficacy is comparable.

Clinical evidence and UK prescribing guidance

Rizatriptan has been evaluated in multiple randomised controlled trials involving thousands of patients.

In pivotal studies, rizatriptan 10 mg provided pain relief (reduction from moderate or severe to mild or no pain) at 2 hours in approximately 67% to 77% of patients, compared with approximately 23% to 40% for placebo.

Complete pain freedom at 2 hours was achieved in approximately 40% to 45% of patients.

Response rates are higher when the dose is taken early in the attack, before pain becomes severe.

Head-to-head comparisons with other triptans have generally shown rizatriptan 10 mg to be among the most effective and fastest-acting oral triptans.

A Cochrane review and network meta-analyses have placed rizatriptan 10 mg alongside eletriptan 80 mg as having the highest efficacy among oral triptans for pain freedom at 2 hours.

NICE CG150 does not recommend one triptan over another but advises trying a different triptan if the first is ineffective or poorly tolerated, as individual response varies significantly between triptans.

The BNF recommends rizatriptan for the acute treatment of migraine and notes the dose adjustment required with concurrent propranolol.

NICE CG150 recommends offering a triptan alongside or instead of an NSAID or paracetamol for moderate to severe migraine, or when simple analgesics have been tried and found inadequate.

Maxalt compared with other triptans

Seven triptans are available in the UK: sumatriptan, rizatriptan, zolmitriptan, naratriptan, eletriptan, almotriptan, and frovatriptan.

They share the same mechanism of action but differ in pharmacokinetic properties, efficacy, and formulations.

Sumatriptan is the most widely prescribed triptan and is available as a pharmacy medicine (50 mg tablets without prescription for adults aged 18 to 65).

It is available in oral, nasal, and subcutaneous injection forms. Rizatriptan has a faster onset and higher 2-hour response rates than sumatriptan 100 mg in most comparative trials.

Eletriptan 80 mg has similar efficacy to rizatriptan but a longer half-life and slower onset.

Naratriptan and frovatriptan have lower efficacy but longer half-lives and may be preferred for menstrual migraine or migraines with a tendency to recur.

Zolmitriptan is available as a nasal spray, which can be useful when vomiting is prominent.

The choice of triptan should be individualised. If one triptan is ineffective or causes unacceptable side effects, it is worth trying at least two others before concluding that triptans are unsuitable.

Dosage and administration

The standard dose of Maxalt for adults is 10 mg, taken as early as possible after the onset of migraine headache.

Do not take Maxalt during the aura phase before the headache begins, as it is less effective when taken before pain onset.

Place the Maxalt Melt wafer on the tongue, where it dissolves rapidly and can be swallowed with saliva. No water is needed.

Conventional tablets should be swallowed whole with water.

If the headache resolves and then returns, a second 10 mg dose may be taken at least 2 hours after the first.

The maximum dose in 24 hours is 20 mg (two doses).

If the first dose has no effect at all on a particular attack, do not take a second dose.

Instead, consider an alternative acute treatment (such as an NSAID) and discuss the response with your prescriber.

For patients taking propranolol, the dose of Maxalt must be reduced to 5 mg, with a maximum of 10 mg in 24 hours.

No dose adjustment is needed for other beta-blockers that do not inhibit MAO-A metabolism.

No specific dose adjustment is needed for mild to moderate renal or hepatic impairment, but Maxalt is contraindicated in severe hepatic impairment.

Side effects of Maxalt

Common side effects

Dizziness, drowsiness, fatigue, tingling or numbness (paraesthesia), and a feeling of heaviness or pressure in the chest, throat, or limbs are commonly reported.

These "triptan sensations" are usually mild, transient, and not indicative of cardiac ischaemia. Nausea, dry mouth, and diarrhoea may occur. Flushing and palpitations are reported occasionally.

Serious adverse effects

Coronary artery vasospasm, myocardial infarction, stroke, and other ischaemic vascular events have been reported very rarely with triptans, almost exclusively in patients with unrecognised cardiovascular disease.

Serotonin syndrome, although rare, is a potentially life-threatening complication of concurrent use with serotonergic medicines. Hypersensitivity reactions, including angioedema and anaphylaxis, have been reported very rarely.

Medication overuse headache

Using Maxalt (or any acute headache treatment) on 10 or more days per month over 3 or more consecutive months can lead to medication overuse headache.

This condition presents as chronic daily or near-daily headache that paradoxically worsens with continued acute treatment.

If you find yourself needing Maxalt frequently, discuss preventive migraine options with your GP or neurologist.

When to seek urgent medical advice

Stop taking Maxalt and call 999 if you develop severe chest pain or tightness, symptoms of a stroke (facial drooping, arm weakness, speech difficulty), or symptoms of a severe allergic reaction (swelling of the face, lips, or tongue, difficulty breathing).

Contact your GP or call NHS 111 if you experience persistent or severe triptan sensations, confusion, agitation with rapid heartbeat, or any symptoms that concern you.

Report suspected adverse reactions to the MHRA at yellowcard.mhra.gov.uk .

Warnings and precautions

Contraindications

Maxalt must not be used in patients with ischaemic heart disease, coronary vasospasm, peripheral vascular disease, uncontrolled hypertension, previous stroke or TIA, severe hepatic impairment, or moderate to severe renal impairment.

It must not be taken within 24 hours of another triptan or ergotamine.

It is contraindicated with concurrent or recent (within 2 weeks) use of a monoamine oxidase inhibitor.

Cardiovascular assessment

Patients with cardiovascular risk factors should be evaluated before starting triptan therapy. In some cases, the first dose may be given under medical supervision.

Triptans cause vasoconstriction and should not be used in patients with established or suspected ischaemic vascular disease.

Drug interactions

Propranolol increases rizatriptan plasma levels; dose reduction is mandatory. MAOIs are contraindicated. Ergot-containing medicines and other triptans must not be used within 24 hours.

SSRIs and SNRIs carry a low but recognised risk of serotonin syndrome when combined with triptans. Discuss all medications with your prescriber.

Pregnancy and breastfeeding

There are limited data on rizatriptan use in pregnancy. It should be used only if the benefit outweighs the risk.

If you are pregnant or planning pregnancy, discuss migraine management with your GP or obstetrician. Limited data on excretion in breast milk; consult your prescriber.

How to get Maxalt in the UK

Maxalt is a prescription-only medicine available through the NHS. Your GP or a headache specialist can prescribe it.

Authorised online prescribers registered with the GPhC can also issue prescriptions after an appropriate consultation.

The standard NHS prescription charge in England is 9.90 pounds per item; prescriptions are free in Scotland, Wales, and Northern Ireland.

Generic rizatriptan is also available and is usually dispensed unless the brand is specifically requested.

Managing migraine: beyond acute treatment

While Maxalt effectively treats individual attacks, a comprehensive migraine management plan may include preventive treatment if attacks are frequent (4 or more per month), severely disabling, or not adequately controlled by acute treatment alone.

NICE CG150 recommends topiramate, propranolol, and amitriptyline as first-line preventive options.

Newer treatments include CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab), which are available through specialist headache services and are recommended by NICE for chronic migraine when three or more prior preventives have failed.

Lifestyle measures, including regular sleep, adequate hydration, regular meals, stress management, and identification of personal triggers, are important complementary strategies.

Sources

• Maxalt 10 mg Tablets, Summary of Product Characteristics (EMC)
• Rizatriptan, British National Formulary (BNF)
• NICE CG150: Headaches in over 12s: diagnosis and management
• Migraine, NHS
• MHRA Yellow Card Scheme