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Each year, 1.4 million people with recent head injuries attend emergency departments in England and Wales. The incidence of head injury in acutely intoxicated patients is estimated to be as high as 65%. One of the challenges of assessing and managing patients who have consumed drugs or alcohol is that the signs and symptoms of this type of intoxication are also risk factors for intracranial complications and head injury, which makes differentiation between the two diagnoses difficult. This article examines the literature on assessment and management of intoxicated patients with head injuries to identify the challenges faced by healthcare professionals undertaking neurological assessments. The article, which includes a case study to illustrate some of these challenges, also explores how staff perceptions can affect assessment and management, and the effects of alcohol on Glasgow Coma Scale scores., Competing Interests: None declared, (©2012 RCN Publishing Company Ltd. All rights reserved. Not to be copied, transmitted or recorded in any way, in whole or part, without prior permission of the publishers.)