<p>The ascending pharyngeal artery (AphA) is a small but important branch of the external carotid artery. It can play multiple roles in various head and neck vascular pathologies. Given the complex roles of AphA in these pathologies, a review of the literature and clinical experience is necessary. This review discusses the following aspects: the angiographic anatomy and variance of the AphA, the role of AphA in endovascular treatment for dural arteriovenous fistulas, the role of AphA in endovascular treatment for head and neck paragangliomas, collateral channels from AphA in extracranial or intracranial artery occlusion, AphA-internal jugular vein fistulas, AphA aneurysms in the head and neck, and epistaxis from pharyngeal trunk rupture. This review demonstrates that the AphA exhibits complex anatomical variations. It supplies blood flow to dural arteriovenous fistulas, head and neck paragangliomas, AphA-internal jugular vein fistulas, and epistaxis cases. Moreover, the AphA serves as both a transarterial treatment route for these conditions and a crucial collateral circulation source in head and neck occlusive or subocclusive vascular diseases. Although rare, AphA aneurysms may develop. Consequently, the AphA constitutes a vital component in head and neck vascular pathologies.</p>