Abstract There is a continuous relationship between blood pressure (BP) and risk of both first and recurrent stroke. Cardiovascular risk approximately doubles with each increment of 20/10 mm Hg, above 115/75 mm Hg. However, most strokes occur in those with “average” BP. In older trials, testing mainly beta-blockers and/or diuretics, lowering BP reduced stroke risk by about one third, within a few years. In more recent trials, ACE inhibitors and calcium antagonists showed similar effects but the more BP is lowered, the greater the stroke reduction. Benefits extend to isolated systolic hypertension in the elderly and the prevention of recurrent stroke. Lifestyle is important. Thiazide diuretics are often recommended as initial treatment, but comorbidities often influence the initial drug choice and most require two or more agents.