Antithrombotic therapy in patients with cervical artery dissection (CAD) is empiric rather than evidence based. The routine use of anticoagulants in each CAD patient cannot be recommended. A randomized controlled trial comparing antiplatelets with anticoagulation is clearly needed. However, due to the large sample size, which is required to gather meaningful results, such a trial is a huge venture. Thus, the matter of antithrombotic treatment in CAD is not expected to be solved in the near future. What should clinicians do in the meantime? There are several pathophysiological arguments in favor as well as against anticoagulants or antiplatelets. Until more data are available, it is our personal recommendation that treatment decisions should be geared to several clinical and paraclinical features of individual patients. The chapter compiles putative arguments in favor versus against immediate anticoagulation and may be helpful for individually tailored antithrombotic treatment decisions in CAD patients.