Although intracranial hypertension may arise from diverse pathology, several basic principles remain paramount to understanding its dynamics; however, the management of elevated intracranial pressure (ICP) may be very complex. Initial management of common ICP exacerbants is important, such as addressing venous outflow obstruction with upright midline head positioning and treating agitation and pain with sedation and analgesia. Surgical decompression of mass effect may rapidly improve ICP elevation, but the impact on outcome is unclear. Considerable effort has been put forth to understand the roles of multimodal intensive care monitoring, osmolar therapy, cerebral metabolic suppression, and temperature augmentation in the advanced management of elevated ICP. Establishing a protocol-driven approach to the management of ICP enables the rapid bedside assessment of multiple physiologic variables to implement appropriate treatments, which limit the risk of developing secondary brain injury.