The rapid development of highly accurate imaging techniques, has led to the discovery of asymptomatic lesions within the pituitary gland that constitute a significant challenge for clinicians and neurosurgeons. These lesions found incidentally are termed incidentalomas and can be observed in approximately 10% of MRI studies performed among healthy subjects. The natural course of these lesions has not been clearly defined. Although some of these masses do not change in size overtime and some may even shrink spontaneously, others have the potential risk to increase in volume and cause symptoms associated with mass effect or hormonal hypersecretion. This review describes the current therapeutic and diagnostic consensus in incidentaloma management, and places special emphasis on hormonal and imaging factors suggestive of high risk tumors.