The link between alcohol and hypertension is well established, yet the mechanism through which alcohol raises blood pressure remains elusive. Possible mechanisms include an imbalance of the central nervous system, impairment of the baroreceptors, an increase of sympathetic activity, stimulation of the renin-angiotensin-aldosterone system, an increase in cortisol levels, an increase of intracellular calcium levels with a subsequent increase in vascular reactivity, stimulation of the endothelium to release endothelin or inhibition of endothelium-dependent nitric oxide production, and chronic subclinical withdrawal. For control of hypertension, cessation or at least reduction of alcohol intake is the first step. Pharmacologic treatment should be withheld until after 2 to 4 weeks of abstinence from alcohol. Alcoholism can result in autonomic neuropathy and cardiomyopathy that can lead to a fall in blood pressure. We believe that angiotensin-converting enzyme inhibitors and calcium channel blockers may be the most appropriate pharmacologic treatment.