POUND
Migraine Diagnostic Criteria
4 of 5 → migraine highly likely (LR+ ~24).
On the AANP exam, headache vignettes ask whether to call a primary headache or escalate to imaging, and POUND nails the migraine half of that question. Pulsatile quality, 4-72 hour duration, Unilateral location, Nausea, Disabling intensity — four of five features yields a positive likelihood ratio around 24 for migraine. Three or fewer should make you reach for SNOOP and rule out secondary causes before treating. POUND positive plus a normal exam supports abortive triptan therapy in a patient without contraindications, and prophylaxis with topiramate, propranolol, or CGRP-blockers when frequency exceeds 4 migraine days per month. Know the cutoff and pair POUND with red-flag screening.
- PPulsatile qualityThrobbing — not dull pressure (that's tension) or stabbing (cluster).
- OOne-day duration (4-72 hours untreated)Tension headaches are usually shorter; cluster is 15-180 min.
- UUnilateralCan shift sides between attacks, but one-sided within an attack.
- NNausea or vomitingPhotophobia and phonophobia are also classic but aren't in POUND.
- DDisabling intensityInterferes with daily activity — patient stops what they're doing.
Clinical Context
POUND operationalizes the IHS migraine criteria into a bedside screen. 4 of 5 gives an LR+ of ~24 for migraine — very likely. 3 of 5 is equivocal (LR+ ~3). 0-2 makes migraine unlikely.
Always screen for SNOOP red flags before treating as migraine — POUND is a rule-in tool, not a rule-out. First-line acute treatment: NSAIDs for mild, triptans for moderate-severe; add antiemetic (metoclopramide, prochlorperazine) for nausea. Prophylaxis (β-blocker, topiramate, CGRP mAb) when attacks are ≥4/month or disabling.
AANP trap: triptans are contraindicated in uncontrolled HTN, CAD, prior MI, stroke, and hemiplegic/basilar migraine.
Related Mnemonics
- ABCD² — TIA Stroke Risk (ABCD² Score)
- AEIOU-TIPS — Causes of Altered Mental Status
- BE FAST — Stroke Recognition (Extended)
- CAM — Delirium Diagnosis (Confusion Assessment Method)
- FAST — Stroke Recognition
Sources
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