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FOUR Score for Comatose Patients

Eye response

4 = eyelids open or opened, tracking, or blinking to command

3 = eyelids open but not tracking

2 = eyelids closed but open to loud voice

1 = eyelids closed but open to pain

0 = eyelids remain closed with pain


Motor response

4 = thumbs-up, fist, or peace sign

3 = localizing to pain

2 = flexion response to pain

1 = extension response to pain

0 = no response to pain or generalized myoclonus status


Brainstem reflexes

4 = pupil and corneal reflexes present

3 = one pupil wide and fixed

2 = pupil or corneal reflexes absent

1 = pupil and corneal reflexes absent

0 = absent pupil, corneal, and cough reflex



4 = not intubated, regular breathing pattern

3 = not intubated, Cheyne–Stokes breathing pattern

2 = not intubated, irregular breathing

1 = breathes above ventilator rate

0 = breathes at ventilator rate or apnea


FOUR = Full Outline of UnResponsiveness.


Related Criteria

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Diagnostic Criteria and Associated Features of Restless Legs Syndrome (RLS)




  1. Wijdicks EF, Bamlet WR, Maramattom BV, Manno EM, McClelland RL. Validation of a new coma scale: The FOUR score. Ann Neurol. 2005 Oct;58(4):585-93. [Medline]

  2. Wijdicks EF. Clinical Scales for Comatose Patients: The Glasgow Coma Scale in Historical Context and the New FOUR Score. Rev Neurol Dis. 2006 Fall;3(3):109-17. [Medline]

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Created: Jan 29, 2007
Last Modified: 10/23/2010

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