Pituitary apoplexy is a clinical syndrome characterised by sudden onset of headache, vomiting, visual impairment and decreased consciousness caused by haemorrhage and/or infarction of the pituitary gland. It usually occurs in patients with pre-existing pituitary adenomas, but has been described in association with a wide range of pituitary pathological entities. In a recent Melbourne series of non functioning pituitary adenomas undergoing surgery, apoplexy was the presenting feature in 11%, while the literature describes an incidence of 2-7%. A high index of suspicion is required as the condition often mimics other causes of acute headache such as sub-arachnoid haemorrhage or meningitis. Precipitating factors should be sought on history. Clinical assessment must include level of consciousness, vital signs and a detailed cranial nerve examination with visual acuity, visual fields and eye movements. Baseline investigation involves full pituitary function, neuroimaging (preferably with MRI) and formal computerised visual fields. Pituitary apoplexy is a genuine endocrine emergency, with the major cause of mortality being acute secondary adrenal insufficiency, therefore “stress” doses of intravenous hydrocortisone are recommended (100mg stat and 50mg 6 hourly). High dose dexamethasone has been used instead of hydrocortisone with the rationale of reducing oedema. There are no comparative data to suggest superior outcome with either glucocorticoid regimen. Many patients can be managed conservatively, with surgical decompression reserved for those with persisting visual loss or deteriorating level of consciousness. Ocular paresis alone is not an indication for surgery in the absence of visual acuity or field abnormalities. When necessary, surgery within one week of presentation results in restoration of vision in the majority. Apoplexy can result in “auto-correction” of functioning tumours, while some form of hormone replacement is required in approximately 80% of patients. Endocrine follow-up is essential for management of pituitary dysfunction and monitoring of residual tumour growth.