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Although the demographics of pediatric idiopathic intracranial hypertension have been well described, the best approaches to its management are less well defined. Recent advances in evaluation of optic nerve status make it easier to determine when and if more aggressive intervention is required. Medical and surgical approaches are discussed.Modern neuroimaging techniques are used to look for secondary causes of intracranial hypertension such as cerebral venous sinus thrombosis. Automated perimetry is now quicker to perform and is accepted as the gold standard in evaluating optic nerve defects, even in the pediatric population. Other newer techniques for assessing optic nerve injury include optical coherence tomography, laser scanning tomography, and spectral Doppler blood flow analysis of the optic nerve head. Medical management remains the first-line treatment, but increasingly, surgical interventions such as optic nerve sheath fenestration and cerebrospinal fluid shunting are used in the pediatric population.Pediatric intracranial hypertension patients may be followed with a greater degree of precision than in the past. Management tends to be similar to that used in adults, now including surgical intervention when indicated. The newer technologies allow us to gather data that may help to determine the optimal time for surgical intervention for those patients who require it.