Several studies have suggested favorable results with endoscope-assisted microvascular decompression (EA-MVD) for treating patients with trigeminal neuralgia (TN); however, supporting evidence is limited.This study aimed to compare the efficacy and safety of EA-MVD with microscopic microvascular decompression (M-MVD).Prospective controlled study.We performed a prospective controlled clinical study that included 52 patients with TN (36, [69.2%] women; 16, [30.8%] men), from June 2021 through January 2022.Patients were assigned to receive either EA-MVD (n = 23) or M-MVD (n = 29). The primary outcome was pain intensity relief, measured using the Visual Analog Scale (VAS) and the Barrow Neurological Institute grading scale. The secondary outcomes were the detection of multiple offending vessels, endoscopic use, operation time, hospital stay length, and complications. All patients were followed-up for >= 12 months.At 12 months, both treatment groups showed similar improvements in pain intensity (P = 0.099). The mean VAS score was 3.5 ± 1.6 and 2.9 ± 1.7 in the EA-MVD and M-MVD groups, respectively. Overall, most patients in both groups reached a pain-free status or had nearly pain-free relief (EA-MVD: 21/23, 91.3%; M-MVD: 27/29, 93.1%). The incidence of multiple offending vessels was higher in the EA-MVD group than in the M-MVD group (52.2% vs 17.2%, P = 0.038). The mean operating time in the EA-MVD group (158 ± 27 minutes) was longer and the hospital stay (6 ± 1 days) was shorter than those of the M-MVD group (144 ± 25 minutes and 8 ± 4 days). No mortality or endoscope-related serious adverse events were noted, with the exception of an intracranial infection case in the M-MVD group.The mean follow-up time was relatively short and a single-center study and a small patient population, which might bring some clinical bias.M-MVD and EA-MVD achieved similar analgesic effects for TN; however, EA-MVD allowed observation of more probable offending vessels with good flexible operative visualization.