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Morning blood pressure (BP) surge (MBPS) is defined as an excessive increase in the morning BP from the lowest systolic BP during sleep and is reported as a risk factor for cardiovascular events in current clinical studies. In this study, we aimed to investigate the relationship between MBPS and carotid intima-media thickness (C-IMT) in prehypertensive patients.We evaluated the association between the rate of BP variation derived from ambulatory BP monitoring and C-IMT in patients with prehypertension.One hundred and seventy patients with prehypertension were included in the study. All office BP measurements and ambulatory 24-h, day-time, and night-time measurements were similar between each group. C-IMT [0.60 (range: 0.57–0.65) vs. 0.55 (range: 0.50–0.60) cm; P<0.001] and the mean platelet volume [8.7 (range: 7.9–9.1) vs. 7.9 (range: 7.3–8.8) fl; P=0.002] were significantly higher in the greater MBPS group than the lower group. In multivariate analysis, male sex [odds ratio (OR): 2.271, confidence interval (CI): 1.011–5.100, P=0.047], greater MBPS (OR: 8.474, CI: 3.623–19.608, P<0.001), and elevated mean platelet volume levels (OR: 3.359, CI: 1.978–5.705, P<0.001) were found to be independent predictors of greater C-IMT in prehypertensive patients.Our study suggests that greater MBPS is associated independently with C-IMT in prehypertensive patients.