Tubercular meningitis (TBM) is a severe central nervous system infection caused by Mycobacterium tuberculosis and remains a leading cause of bacterial meningitis in high-burden countries. Despite being universally fatal if left untreated, significant challenges persist in achieving timely diagnosis and establishing optimal treatment strategies, with many current protocols still derived from pulmonary tuberculosis management. This chapter explores the complexities of TBM, highlighting the diagnostic hurdles posed by its paucibacillary nature, nonspecific symptoms, and the limitations of current cerebrospinal fluid (CSF) analysis, including neuroimaging and microbiological tests. Furthermore, it addresses critical treatment dilemmas, such as the differential permeability of antitubercular drugs into the CNS, the role of high-dose regimens, the potential benefit of adjunctive therapies like corticosteroids and immunomodulators, and the management of drug-resistant cases. By synthesizing current evidence and guidelines, this chapter provides a comprehensive overview of the ongoing challenges and the need for a multidisciplinary approach to improve clinical outcomes for TBM patients.