Children commonly seek attention in emergency departments following head injury. Head computed tomography (CT) is often used to decide subsequent disposition. Clinical criteria predicting CT abnormalities would allow effective and timely treatment and minimize unnecessary procedures depleting overburdened medical resources. We prospectively compared presenting clinical features with subsequent emergent head CT in 300 children less than 19 years old over a nine-month period. The disposition of patients following imaging was also recorded. Only suspected abuse was more than 50% positively predictive in children below age two and those above age two. Two signs were more than 67% positively predictive in both age groups: focal motor deficit and pupillary asymmetry. Patients with abnormal CTs were the only children to undergo emergent neurosurgery (30%) and were nearly five times as likely to be intensively monitored. Children with normal CTs were nearly five times as likely to be observed in a routine department or at home. We conclude that no single clinical feature can predict with certainty an abnormality on immediate head CT. However, children suspected of being abused, and those with focal motor deficits or pupillary asymmetry, should be imaged. Finally, emergent CT when judiciously ordered likely reduces unforeseen morbidity and minimizes costly intensive care observation.