Normal pressure hydrocephalus (NPH) is divided into idiopathic (iNPH) and secondary causes such as tumors, infections, trauma, or intracranial hemorrhage. More people are now overweight, and BMI correlates with CSF pressure so many patients have higher CSF pressure making the “normal” in NPH a partial misnomer. The dominant symptom is gait impairment often accompanied by cognitive and urinary difficulty. NPH requiring treatment is relatively rare but potentially underdiagnosed. A clinical approach to NPH should start with a differential diagnosis of the gait difficulty, as in early stages, patients may not have the full symptom triad. Those with anomia may have Alzheimer’s dementia or primary progressive aphasia, and there can be additional patients with concomitant NPH and other disorders such as Alzheimer’s, Parkinson’s, and cervical myelopathy that may require treatment of both pathologies. The most useful diagnostic tests in the workup of NPH include magnetic resonance imaging (MRI) of the brain and a CSF drainage trial, with either high volume lumbar puncture or lumbar drain trial, with the videotaping of the gait before and after the CSF removal. The primary treatment remains a CSF diversion procedure with placement of a shunt, and several shunt surgical advances have resulted in less mortality and morbidity.