Background <p>The proportion of older adults with head and neck cancer is steadily rising. Treatment planning in this population is often challenging due to more frequent comorbidities; reduced physiological reserves; and, at times, differing treatment goals. Additionally, older adults have been significantly underrepresented in pivotal radiotherapy trials, making evidence-based decision-making difficult.</p> Objective <p>This article strives to present current controversies in the radiotherapeutic management of older adults with head and neck cancer.</p> Methods <p>A&#xa0;selective literature search for studies addressing radiotherapy in elderly head and neck cancer patients was conducted via PubMed and ClinicalTrials.gov.</p> Results <p>Geriatric screening tools such as the G8 test are associated with treatment adherence and survival but are still rarely implemented in routine clinical practice. The SENIOR cohort study (NCT05337631) demonstrated a&#xa0;survival benefit for the combination of radiotherapy with concurrent chemotherapy in older patients with good performance status and few comorbidities, but not for the combination with cetuximab. Current studies are investigating hypofractionated radiotherapy regimens and novel agents for patients with contraindications to cisplatin. For patients ineligible for curative treatment, effective palliative radiotherapy concepts with shortened overall treatment duration are available.</p> Conclusion <p>The management of older adults with head and neck cancer remains challenging and requires further prospective research. Advanced age alone should not be considered a&#xa0;contraindication to curative radiotherapy, including concurrent chemotherapy. For patients not eligible for curative treatment, various palliative radiotherapy regimens are available.</p>