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Injuries caused by motorcycle crashes are one of the major public health burdens leading to high mortality, functional disability.This study aimed to measure the protective effect of motorcycle helmet use on mortality and intracranial injury and to compare the preventive effect in drivers and passengers.This is a cross-sessional study based on the Emergency Department(ED)–based Injury In-depth Surveillance (EDIIS) database from 23 EDs in Korea. All of trauma patients injured in motorcycle crashes between January 1, 2013 and December 31, 2016 were eligible, excluding cases with unknown helmet use and outcomes. The primary and secondary outcomes were and in-hospital mortality and intracranial injury. Using interaction models, we compared the protective effect of helmet use on outcomes across driving status (driver and passenger)Among 17 791 eligible patients, 10 668 (60.0%) patients were wearing helmets at the time of the crash, 2128 (12.0%) patients had intracranial injuries and 331 (1.9%) patients had in-hospital death. 16 381 (92.1%) patients were drivers and 1410 (7.9%) patients were passengers. 62.6% in drivers and 29.1% in passengers were wearing helmets at the time of the crash. Compared to un-helmeted group, the helmeted group was less likely to have in-hospital mortality (1.0% vs 3.2%, AOR: 0.29 (0.22–0.37))and intracranial injury(8.0% vs 17.9%, AOR: 0.43 (0.39–0.48)). In the interaction model, there was a significant preventive effect of helmet use on in-hospital mortality in driver(AOR: 0.26 (0.21–0.34)) but not in passengers(AOR: 1.32 (0.52–3.35). AORs (95% CIs) of helmet use for intracranial injury were 0.42 (0.38–0.47) in drivers and 0.61 (0.41–0.90) in passengers, respectively.Wearing helmets in motorcycle crashes reduced in-hospital mortality and intracranial injuries. There was a significant preventive effect of helmet use on in-hospital mortality in driver but not in passengers. The preventive effect of motorcycle helmet use on intracranial injury was stronger in drivers than in passengers.