This review of the effectiveness of treatment for acute stroke and methods of secondary prevention shows that the highest priority for providers of a stroke service must be to establish a stroke unit and multidisciplinary team that delivers organised stroke care. Acute ischaemic stroke patients should be immediately started on aspirin 300 mg daily, and, if possible, many of them should be entered into further trials of thrombolysis and other promising treatments. After the acute phase, aspirin should be continued in a lower dose, 75 mg daily; smoking should be discouraged; high blood pressure treated initially with a diuretic; and fibrillating ischaemic stroke/transient ischaemic attack survivors anticoagulated long-term with warfarin or given aspirin if anticoagulation is not sensible. Statins are probably indicated in patients who already have symptomatic coronary heart disease. Adding dipyridamole to aspirin, substituting clopidogrel for aspirin, and carotid endarterectomy are all expensive interventions to prevent stroke, but if ways could be found to focus them on those patients at especially high risk, they would become more affordable.