Background: In older adults, hypertension significantly contributes to small vessel disease associated with the brain, and it often leads to a structural alteration of the brain that can be seen on MRI scans. Chronic hypertension results in white matter hyperintensities, lacunar infarcts, and brain atrophy that can be sustained and consequently lead to impairments in cognitive and functional ability. To assess the association between hypertension and white matter changes observed in MRI scans of elderly patients. Methods: This cross-sectional study was carried out in the Medicine Department of Saidu Teaching Hospital, Swat, from Janurary 3rd to July 5th, 2024. A total of 249 elderly patients aged 60 years and older undergo MRI brain imaging. Demographic, clinical, and radiological information were collected through a well designed questionnaire. White matter changes were evaluated with the use of the Fazekas scale. Chi-square tests and binary logistic regression were used to find statistically significant associations with p value under 0.05. Results: White matter hyperintensities were found among 73.1% of the study. The prevalence was marked among hypertensive patients (86.6%) as opposed to non-hypertensives (47.1%). Hypertensive patients had higher Fazekas scores, more lacunar infarcts, and greater brain atrophy. Logistic regression analysis showed that hypertension, older age, and poorly controlled blood pressure were the most important predictors of changes in white matter. Conclusion: This investigation observed a significant correlation linking hypertension with structural brain abnormalities in older patients. These results highlight the necessity for timely intervention and control of hypertension to reduce the likelihood of cognitive deterioration in this group of people.