Objective To explore the surgical method and effect of endoscopic microvascular decompression for the treatment of primary trigeminal neuralgia. Methods 23 cases with primary trigeminal neuralgia received endoscopic microvascular decompression. During operation, the responsible vessels were confirmed, pushed aside and padded with Tefelon cotton. Results The pain got relieved postoperatively in all cases with an effective rate of 100%. The responsible blood vessels included anterosuperior cerebellar artery, anteroinferior cerebellar artery, posteroinferior cerebellar artery, basilar artery, and petrous. Conclusion Endoscopic microvascular decompression is an effective therapeutic method for primary trigeminal neuralgia, and the nerve function should be kept intact.