Systolic hypertension is difficult to control in the elderly, but this is not an excuse for denying these patients the benefits of carefully controlled antihypertensive treatment, particularly when target organ disease is present. Although drug therapy may produce alarming symptoms, it is highly doubtful that it increases the incidence of myocardial infarction or permanent neurologic damage. In fact, evidence indicates that antihypertensive therapy may prevent hemorrhagic and thrombotic strokes. Arterial pressure should be reduced slowly and cautiously--to allow control without interfering with cerebral flow stability. Drug therapy should be started in small doses and may be initiated with diuretics. Methyldopa in small or moderate doses has been effective and does not often cause postural hypotension. Drugs that interfere with reflex arteriolar constriction should not be used.