Tuberculous meningitis (TBM), the most severe manifestation of extrapulmonary tuberculosis, poses significant global health challenges due to its high mortality rates and complex pathophysiology. This review synthesizes recent findings on TBM, covering epidemiology, pathogenesis, clinical manifestations, diagnostics, and management strategies. TBM disproportionately affects immunocompromised populations, including individuals with HIV, with the highest mortality observed in low-resource settings. Pathogenesis involves Mycobacterium tuberculosis breaching the blood-brain barrier, eliciting a granulomatous inflammatory response that contributes to neurotoxicity. Advances in diagnostics, such as next-generation sequencing and novel imaging techniques, have improved early detection and treatment guidance. Management strategies emphasize multidrug regimens, adjunctive corticosteroids, and emerging therapies like intrathecal administration and nanoparticle-based drug delivery. Host-directed therapies targeting immune modulation and oxidative stress show promise in improving outcomes, particularly for drug-resistant TBM. Despite advancements, diagnostic delays, treatment resistance, and high rates of neurological effects underscore the need for further research. Preventive strategies focusing on early diagnosis, modifiable risk factor management, and public health interventions are critical to reducing global burden of TBM. This review highlights the importance of integrating innovative diagnostics, tailored treatments, and preventive measures to address the challenges of TBM and improve patient outcomes.