OBJECTIVE Gunshot wounds to the head are rare in Europe. They may be inflicted by low-velocity handguns, captive bolt guns and tear gas cartridges and mostly result from suicide attempts. The experience of neurosurgeons with this kind of traumatic injury is decreasing; the aim of this study was therefore to analyse prognostic factors which help to decide whether or not to operate and to discuss treatment options. METHODS Thirty patients with gunshot head injuries treated in our hospital from 1993 to 2008 were retrospectively evaluated. Glasgow Coma Scale (GCS) score, pupil reactivity, lesion localisation, number of bone fragments, intracranial pressure (ICP), midline shift, hypotension, and dural penetration were analysed for their prognostic value. Surgically and non-surgically treated patients were evaluated separately. Complications were registered. RESULTS A low GCS of 3-8, fixed pupils, >2 bone fragments, bilobar or posterior fossa/brainstem lesions and ICP >45 mmHg were indicators of a poor prognosis. CONCLUSIONS Patients with a GCS of 3-8 and two non-reactive pupils should not be operated. If one or both of the pupils are reactive, surgery should be performed irrespective of the GCS score, except in patients with translobar/transventricular wounds. Even if there are no clear contraindications to surgery, the outcome is expected to be poor in patients with a low GCS score, midline shift >10 mm, >2 bone fragments in the brain, and a bilobar, posterior fossa/brainstem or ventricular lesion and ICP >45 mmHg. When surgery is performed the wound and the missile or bone track should be debrided meticulously, the wound and dura should be closed in a watertight fashion and antibiotic prophylaxis as well as tetanus serum should be given.