Head injuries are a common chief complaint in clinics, urgent care facilities, and emergency departments (ED) alike. In the setting of known head injury, the possibility for significant pathology can be daunting for clinicians. The decision to obtain advanced imaging should be guided by evidence-based medicine; however, in many cases, imaging or transfer to a higher level of care is viewed as unnecessary. Few studies have evaluated head injuries and concussions in the emergency department in comparison to imaging guidelines. The purpose of this study was to evaluate patients presenting to our rural, Level 1 trauma center ED with head injuries. In this retrospective cohort study, data were obtained from our West Virginia University Hospital electronic medical record (EMR) from January 1 to December 31, 2015 regarding patients who presented to our ED and had a final diagnosis of a head injury or concussion. Data points extracted from the EMR and analyzed descriptively included age, sex, method of arrival, whether patients were transferred from an outside facility, if any advanced imaging was conducted at another facility, whether imaging guideline usage was indicated, if the injury was sports-related, and disposition. In 2015, there were 691 patients who presented to our ED and received a final diagnosis of a head injury or concussion. The median age was 23 years, ranging from 0 to 93 years, and 71% were male. The most common mode of arrival was via ambulance (43%). Approximately 20% of these patients were transferred to our ED from an outside facility. Only 120 cases (17%) were sports-related injuries. Of those, 58 (48%) received advanced imaging and one received MRI. However, 477 of the 571 (84%) non-sports-related injuries received CT imaging. Sixty-five percent of patients received a CT scan in our ED. Of those, 25% had a positive result; 88% of these were admitted as inpatient. About 48% of all patients were discharged from the ED. Of the remaining 356 patients, 219 (62%) were admitted as inpatient. Utilization of evidence-based imaging guidelines was only seen in patients less than 18 years of age, but inconsistently. Although limited by the retrospective nature of the study, we demonstrated characteristics of patients who presented to our ED and were ultimately diagnosed with a head injury or concussion. A small portion of our cases were sports-related injuries. In younger patients with sports-related injuries, the decisionmaking process regarding obtaining CT imaging was more frequently documented, though few notes mentioned evidence-based guidelines. Further research is needed in this area in order to develop potential interventions for implementing consistent clinical imaging guidelines in ED settings.