Malignant hypertension still remains a severe condition that requires early recognition and treatment. The therapy has evolved from extreme measures in the first 70 years of the last century to intravenous treatment with modern antihypertensive treatment. Today, in the absence of trials and solid evidences, there are no formal guidelines on how to treat MHT. There is a relative consensus on a treatment based on intravenous infusion of antihypertensive treatments in the first days. This review summarizes the historical background and pathophysiological evidences which led to the actual most common pharmacological management of this condition but also can contribute to challenge this management. Oral treatment starting with low dose angiotensin converting enzyme inhibitors appears as a solid option and may improve the management of malignant hypertension in low-income countries where this form of hypertension remains relatively frequent. Future developments are considered according to the latest progress on the topic.Le texte complet de cet article est disponible en PDF.