This study aimed to compare injuries sustained by motorcycle drivers with those sustained by pillion passengers in fatal head-on motorcycle collision accidents. We examined 84 cases of fatal head-on motorcycle collision accidents, causing 79 deaths of drivers and 19 deaths of pillion passengers, using medical and medico-legal examination records. The distribution of superficial injuries, characteristic injuries, injury severity as well as fatal causes was evaluated and compared using χ(2) tests. The results revealed a significant difference in the distribution of superficial injuries between drivers and passengers. The proportions of injuries in the hand and perineum regions were significantly higher in drivers than passengers. Some characteristic superficial injuries on the palms, chest, abdomen as well as the perineum areas were observed in drivers, while none of these characteristic injuries were observed in pillion passengers. Drivers were found to have suffered more severe chest and abdomen injuries than passengers. In addition, there was a higher incidence of fatalities involving run-over injuries for drivers compared with pillion passengers. The proportion of fatal injuries related to tumbling was higher for passengers than for drivers. Overall, our results revealed a difference in injury severity, superficial injury distribution and characteristic injuries between drivers and passengers. Few characteristic injuries were found in pillion passengers. These findings could help to guide medico-legal examinations, particularly in identifying drivers among victims involved in traffic accidents.