The medical treatment of patients with symptomatic intracranial atherosclerotic disease (ICAD) is directed toward reducing the risk of new ischemic events. The overall strategy is divided into: (1) prevention of occurrence of intraluminal thrombus, with or without embolism; (2) plaque stabilization and regression; and (3) management of atherogenic risk factors. In patients with ICAD, short-term and long-term anticoagulation (compared with aspirin) has not shown to be beneficial. The current guidelines recommend that aspirin monotherapy, the combination of aspirin and extended release dipyridamole, and clopidogrel monotherapy (rather than oral anticoagulants) are all acceptable options in patients with noncardioembolic ischemic stroke and transient ischemic attack. The findings of another pilot trial suggest that symptomatic ICAD is a dynamic lesion and cilostazol may prevent its progression. Overall, the subgroup analysis from randomized trials, provide evidence about benefit of aggressive atherogenic risk factor management among patients with ICAD. Current guidelines recommend statin therapy with intensive lipid-lowering effects for patients with atherosclerotic ischemic stroke or transient ischemic attack with or without known coronary artery disease to reduce the risk of stroke and cardiovascular events.