A 28-year-old woman presents to the clinic with a 2-year history of recurrent headaches occurring 1–2 times per month. She describes the pain as a throbbing, pulsating sensation typically on the right side of her head. Each episode lasts approximately 12 hours, and she is usually nauseated during the attacks but does not vomit. The pain is severe enough that she has to leave work and lie down in a dark, quiet room until it resolves. She denies fever, recent URI symptoms, vision changes, or aura. Vital signs and neurologic exam are unremarkable. Applying the POUND criteria, which of the following is the most likely diagnosis?

Question

Accepted Answer

✅ C. Migraine without aura
The POUND mnemonic stratifies the likelihood of migraine: Pulsating quality, hours-Onset duration of 4–72 hours, Unilateral location, Nausea, and Disabling intensity. Meeting ≥4 features makes migraine highly likely (likelihood ratio ~24); meeting 3 makes it likely (LR ~3); meeting ≤2 makes migraine unlikely. This patient meets all 5 POUND criteria — pulsating, 12-hour duration (within 4–72 h), unilateral, nausea, and disabling enough to require leaving work and lying down. With no aura described, the diagnosis is migraine without aura.

❌ A. Tension-type headache
Tension headaches are typically bilateral, described as a "band-like" pressing or tightening (not pulsating), of mild-to-moderate intensity, and not aggravated by routine activity. Patients usually continue normal activities. The pulsating quality, unilateral location, and disabling severity in this case point away from tension headache.

❌ B. Cluster headache
Cluster headaches are strictly unilateral and severe, but they are typically periorbital/temporal and stabbing in quality (not throbbing), last 15–180 minutes (not hours-long), occur in clusters of multiple attacks per day for weeks, and are accompanied by ipsilateral autonomic features (lacrimation, conjunctival injection, ptosis, rhinorrhea). Cluster headaches predominantly affect men. This patient's pattern does not fit.

❌ D. Sinus headache
Sinus headache (acute rhinosinusitis) is associated with facial pressure or pain over affected sinuses, purulent nasal drainage, nasal congestion, and often fever or recent URI. It is not typically pulsating, unilateral cranial, or accompanied by isolated nausea, and it does not recur in this episodic pattern over 2 years. Many patients self-diagnose "sinus headaches" that are actually migraines.

:::tip
POUND — 4 or 5 features = highly likely migraine. Even 3 features yields a meaningfully elevated likelihood ratio. If a patient hits all 5, do not waste time considering tension or sinus headache.
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POUND

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