Spontaneous dissection of the internal carotid artery is a leading cause of stroke and TIA, particularly in young patients. The antithrombotic treatment with or without an interventional procedure is a unanimously accepted indication for the prevention of the ischemic events in these patients. Whether anticoagulants or antiplatelets as antithrombotics are a better option is a matter of debate. The authors, based on clinical and pathophysiological data in the published studies and their own experience argue in favour of antiplatelets in most cases, without excluding the need of anticoagulants in some cases, due to the lack of objective proofs for the superiority of anticoagulants in this pathology and at the same time, a better safety profile of antiplatelets. To have a clear-cut answer to this debate, a large comparative randomized clinical trial between the two types of treatment is desirable.