Family physicians play a pivotal role in stroke prevention (primary and secondary) and early management of stroke in developing countries. The objective of this study was to evaluate whether Pakistani family physicians' approach to stroke prevention and management was in accordance with established international guidelines. This was a cross-sectional survey of randomly selected family physicians in Pakistan, conducted in 2007. A total of 588 family physicians participated in the study. The data reveal that 88% of the physicians are aware of at least one of the 5 major symptoms of stroke, but only 46% are able to correctly idenitfy all 5 symptoms; 93% of the physicians check blood pressure in their adult patients regularly, and 63% use a cutoff of 140/90 mm Hg to start antihypertensive therapy in routine clinical practice; 90% ask their patients about cigarette smoking or tobacco use, but only 64% regularly advise their patients to quit smoking; 75% do not routinely check cholesterol levels in their patients; 36% treat patients with stroke by themselves, whereas 64% prefer to refer these patients to a specialist or hospital; 57% use intravenous or sublingual antihypertensive medications in patients with acute stroke with blood pressure >160/100 mm Hg; and 95% use antiplatelet agents for stroke prevention, with 70% using aspirin and 28% using clopidogrel as first-line antiplatelet therapy. These data indicate a substantial gap between international guidelines and Pakistani family physicians' management of stroke patients. There is an urgent need for stroke-related continuing medical education to propagate stroke management guidelines.