Accurate positioning remains a central challenge in head and neck radiotherapy because highly conformal dose distributions are delivered near multiple critical organs, and clinically relevant discrepancies may not be resolved by rigid image-guided correction alone. This narrative review synthesizes evidence on positioning management in head and neck radiotherapy, with particular emphasis on the transition from couch correction to action-oriented clinical decision-making. Peer-reviewed studies, guidelines, and key reviews published between January 2005 and April 2026 were identified using PubMed/MEDLINE and reference screening. Positioning uncertainty is often region-specific and dynamic, reflecting lower-neck and shoulder mismatch, mandibular variation, mask-fit deterioration, functional motion, and progressive anatomical changes during treatment. Thermoplastic immobilization, customized headrests, bite blocks, cone-beam computed tomography, six-degree-of-freedom correction, and adaptive workflows have improved reproducibility and verification; however, these approaches do not eliminate mismatches caused by non-rigid posture, immobilization failure, or evolving anatomy. In such situations, the key clinical task is to distinguish rigid setup deviations suitable for online correction from discrepancies requiring repositioning, re-immobilization, repeat simulation, or adaptive replanning. Emerging technologies, including artificial intelligence, dose-of-the-day estimation, corrected CBCT, synthetic CT, rapid replanning, and workflow-integrated decision support, may help close the gap between mismatch detection and intervention selection. Positioning management should therefore evolve from a correction-centered model to an action-oriented framework that links observed geometric or anatomical change to the most appropriate clinical response.