Blood pressure lowering in hypertensive patients is of significant importance. The complex pathophysiology makes the therapeutic targets many, and extensive research has provided us with many antihypertensive drugs. However, data indicate that the proportion of patients with controlled blood pressure is far from satisfying. This may partly be explained by a lack of individualized treatment. Present guidelines for management of hypertension emphasize that a thorough evaluation of the patient is necessary before initiating treatment. Based on information about gender, age, ethnicity, family history, clinical examination and concomitant diseases like diabetes mellitus, coronary heart disease, heart failure, cerebrovascular disease and gout, the physician is able to provide the best treatment. However, most patients need two to three drugs to control the blood pressure. Thus, we need methods to predict blood pressure responses to the various drugs in the individual patients. Possibly, in the future treatments may be based upon genetic variants. Until now, several polymorphisms in genes regulating blood pressure have been located, and these may influence responses to drugs. However, the results are heterogeneous and contradictory, and we are yet not capable of determining the best treatment based on genetic properties. Coming years challenge us to further clarify these potentially important aspects of treatment. Meanwhile, physicians are obligated to individualize the treatment by other means, based on disease history, concomitant diseases and clinical examination.