Intracranial hypertension is one of leading causes of mortality after acute brain injury. Its causes and origins are multiple. The approach should be based on the underlying pathophysiology. There are different therapeutic modalities to control increased intracranial pressure (ICP), but all share the objective of normalizing basic physiologic variables. ICP control should be combined with adequate cerebral perfusion pressure. The classic approach to ICP control is unidirectional and sequential escalation of therapy. The nonresponse to classic therapy signaled a refractory condition. Multimodal monitoring has emerged as a useful tool, taking into account the analysis of ICP, oxygenation, and cerebral metabolism.