Moyamoya disease (MMD) is a cerebrovascular disorder characterized by progressive stenosis of the terminal portion of the internal carotid artery and proximal middle cerebral artery, along with the formation of abnormal compensatory collateral vessels at the base of the brain. It confers dual risks of both ischemic and hemorrhagic stroke, making the formulation of clinical treatment strategies highly challenging. Antiplatelet therapy serves as the cornerstone of medical treatment for ischemic MMD. However, its exact efficacy in improving cerebral hemodynamics remains unclear. Furthermore, due to the potential risk of hemorrhagic transformation, its clinical application remains controversial. Although antiplatelet therapy holds theoretical promise for secondary stroke prevention in MMD, findings from studies in Asian populations have been inconsistent, particularly regarding the benefits of primary stroke prevention after a radiological diagnosis of asymptomatic MMD. This review synthesizes current evidence on the pathophysiological basis, current clinical status, safety controversies, and pharmacological selection strategies of antiplatelet therapy for MMD. Its aim is to provide a theoretical foundation to guide precision clinical decision-making and inform the design of future.