The awake craniotomy is an important technique used for brain tumour excision from eloquent cortex, epilepsy surgery, and deep brain stimulation surgery. It has been used, less commonly, in the management of mycotic aneurysms and arteriovenous malformations near critical brain areas. The benefits are considered to be of increased lesion removal, with growing evidence of improved survival benefit, whilst minimizing damage to eloquent cortex and resulting postoperative neurological dysfunction. Other advantages include a shorter hospitalization time, hence reduced cost of care, and a decreased incidence of postoperative complications such as nausea and vomiting. The concept of an awake craniotomy predates the existence of anaesthesia and in ancient times, trephining of the skull was used to get rid of ‘evil air’. It is a procedure that has gained in popularity because of advances in diagnosis, intra-operative functional neurosurgical technology, developments in anaesthetic agents and monitoring, and the patient’s expectations. The term ‘awake craniotomy’ is misleading as the patient is not fully awake for the entirety of the procedure. The more surgically stimulating parts of the procedure require varying levels of sedation, or anaesthesia. The patient is fully awake during the mapping procedure during which lesion resection takes place. The common anaesthetic techniques used are sedation only or general anaesthesia, and awaking the patient for cortical mapping and resection, with the option of re-anaesthetizing for closure. The patient has a scalp block inserted for pain relief usually for all anaesthetic approaches. Occasionally the anaesthetic technique of awake with a scalp block alone is utilized, this can be useful in elderly patients. The anaesthetic considerations for an awake craniotomy can make it challenging, and this article will consider the issues involved.