Lower extremity arterial insufficiency, a relatively common complication of ergotamine ingestion, is a rare complication of methysergide therapy for migraine headaches. Methysergide causes one of two typical angiographic patterns: intra-abdominal extrinsic compression of the aorto-iliac vessels in patients with retroperitoneal fibrosis, or marked diffuse bilateral spasm of the superficial femoral arteries in those without retroperitoneal fibrosis. We report a patient with methysergide-induced bilateral lower extremity arterial spasm and review the relevant literature. When one of the above arteriographic patterns is recognized, methysergide ingestion should be considered as a possible etiology.