In brief: More than 42,000 injured horseback riders are treated each year in emergency departments. Although most of the injuries are relatively minor, as many as one third involve the CNS. Neurologic injuries are usually to the head-mostly concussions or cerebral contusions-and commonly occur when a rider falls from the horse. Certain medical conditions, eg, temporary paralysis and posttraumatic epilepsy, contraindicate equestrian activities. The risk of catastrophic injury may be lessened by identifying the persons who should not participate and enforcing the use of protective equipment-particularly adequate headgear.