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To see if early tracheostomy (fifth day) reduces duration of mechanical ventilation, ICU stay, incidence of pneumonia and mortality in comparison with prolonged intubation (PI) in patients with head injury.Patients were prospectively included in this study if they met the following criteria: isolated head injury, Glasgow coma scale (GCS) score ≤8 on first and fifth day, with cerebral contusion on CT scan. On the fifth day, randomization was done in two groups: early tracheostomy group (T group, n = 31) and prolonged endotracheal intubation group (I group, n = 31). We evaluated total time of mechanical ventilation, ICU stay, pneumonia incidence and mortality. Complications related to each technique were noted. Analysis of data were performed using Yates and Kruskall Walis tests. p < 0.05 was considered significant.The two groups were comparable in term of age, sex, and Simplified Acute Physiologic Score (SAPS). The mean time of mechanical ventilatory support was shorter in T group (14.5 ± 7.3) versus I group (17.5 ± 10.6) (p = 0.02). After pneumonia was diagnosed, mechanical ventilatory time was 6 ± 4.7 days for ET group versus 11.7 ± 6.7 days for PEI group (p = 0.01). There was no difference in frequency of pneumonia or mortality between the two groups.In severe head injury early tracheostomy decreases total days of mechanical ventilation or mechanical ventilation time after development of pneumonia.