Hypertension affects approximately 46% to 48% of US adults, with severe blood pressure elevations (180/110-120 mm Hg or higher) observed in more than 13% of individuals with preexisting hypertension. In the absence of new or worsening target organ damage, this is defined as severe hypertension. Although guidelines provide structured approaches to chronic hypertension management, guidelines for management of acute severe hypertension are limited. In the outpatient setting, medication nonadherence is the most common cause of severe hypertension. This typically requires reinitiating or increasing the dosage of antihypertensive therapy. Out-of-office blood pressure monitoring is recommended, and barriers to adherence should be investigated. In hospitalized patients, transient blood pressure elevations are often triggered by secondary factors such as anxiety, hypervolemia, pain, or withdrawal of home medications. Randomized and observational trials have shown that inpatient treatment of severe hypertension does not improve short-term outcomes but increases the risk of cardiovascular events and acute kidney injury and the length of hospitalization. Use of short-acting or intravenous antihypertensive medications is associated with adverse outcomes and is not recommended. Evaluation for secondary hypertension is recommended in cases of resistant hypertension, progressive blood pressure elevation, age of onset younger than 30 years, or evidence of premature target organ damage.