Central pontine myelinolysis represents a relatively contemporary neurologic entity in which an imbalance of water relative to alterations in the body's electrolyte levels induces characteristic demyelination in the central part of the basis pontis as well as extrapontine sites. The clinical scenario is typically one of chronic hyponatremia followed by a rapid correction to normonatremic or hypernatremic levels. This seemingly innocuous series of events can result in fatal consequences. Better understanding of the pathophysiology of this disorder provides avenues for clinical management, including use of steroids and organic osmoles, such as myoinositol. More recently, the introduction of a newer class of pharmacologic agents - the vasopressin receptor antagonists, known as vaptans, which induce an excretion of increased amounts of water without altered sodium or potassium excretion - is of particular interest. This review addresses classic approaches to the management of this disorder along with a discussion of newer pharmacologic agents that may become important therapeutic interventions in the clinical management of the osmotic myelinolysis syndrome.