Severely elevated blood pressure (BP) is commonly encountered in acute care settings. Initial evaluation of patients with severe hypertension should focus on determining the presence and extent of acute target organ damage. Hypertensive emergencies are life-threatening conditions that require immediate reduction of BP in an intensive care unit. Hypertensive urgencies-and severe uncontrolled hypertension also require prompt attention with gradual lowering of BP. There are a number of drugs available for the treatment of these disorders. Careful reduction in BP with special attention to cerebral circulation is key to managing these patients.