Tension pneumocephalus is an uncommon and life-threatening neurological condition. It requires emergent and immediate attention to prevent fatal complications. Head injury is the most common cause of tension pneumocephalus. Air can gain access into the cranium either through a fracture involving paranasal sinus or the middle ear cavity or even more rarely in association with a compound depressed fracture of the skull vault. Its management includes simple twist drill and aspiration of intracranial air with or without placement of an under water seal. 100% oxygen should be administered by a non-breatheable mask which hastens the resorption of air. The authors report a series of 4 cases of post-traumatic tension pneumocephalus, highlighting its management, and review the pertinent literature.