Head and neck high-flow vascular malformations are uncommon lesions whose management presents a clinical challenge. Although in some rare cases a complete cure is possible, in the vast majority the primary objective is symptom control, cosmesis improvement, and preservation of vital functions. Striving for "complete" treatment in most cases results in potentially devastating clinical and cosmetic outcome. Collateral supply via intracranial vessels is not uncommon, and scrupulous efforts to avoid complications related to inadvertent intracranial embolization or venous thrombosis are mandatory. Regardless of therapeutic goal, close long-term follow-up for lesion recurrence is necessary. Recent demonstration of syndromic associations for some subsets of HFVMs holds out the promise of the future development of medical therapy for these difficult lesions.