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Motorcycle helmet laws vary by state, with Kentucky requiring helmets only for younger riders. We hypothesized that motorcyclists injured in Kentucky and seen at a Tennessee trauma center would be more likely to be unhelmeted, have more severe head injuries, and sustain more fatal injuries than those injured in Tennessee or Virginia.A Trauma Registry review of 729 injured motorcyclists from January 2005 through June 2015 examined state location of crash, demographics, helmet use, and clinical outcomes. Multivariate logistic regression analysis evaluated predictors for head injury severity and death.Unhelmeted motorcycle rider status predicted more severe head injuries (relative risk 15.3, P < 0.001) and death (relative risk 4.2, P < 0.001). Motorcyclists injured in the state of Kentucky were more likely to be unhelmeted, require an operative procedure, have more severe head injuries, have longer lengths of stay, and sustain more fatal injuries (all with < 0.001) than motorcyclists injured in Tennessee or Virginia.This study lends support for maintaining and enforcing current universal motorcycle helmet laws for all ages in states where they are in effect and for upgrading helmet laws that apply only to some riders.