Approximately two-thirds of head and neck cancer (HNC) patients present with locoregionally advanced stage (III and IV) disease. This requires multimodality therapy, including surgery, radiation, and/or chemotherapy. Despite recent advances in treatments for HNC, the treatment paradigms in the elderly population have not been well defined. These patients may not be considered candidates for aggressive multimodality management due to multiple comorbidities, general debility, and concerns regarding poor treatment tolerance and toxicities. The aim of this review is to highlight some of the pertinent issues in dealing with the increasing elderly HNC population, the increasing complexity and toxicities associated with combined modality treatments, and how comorbidity and age are considered during treatment selection decisions. The challenges being faced regarding potential interactions of older age and comorbidity, and their impact on prognosis and quality of life are reviewed, with a special emphasis on radiation therapy or combined modality therapy. Possible solutions to help delineate further areas of study addressing key questions in management of elderly HNC patients are discussed.