Microvascular decompression (MVD) is a highly accepted and effective method for treatment of patients with trigeminal neuralgia in whom compression of the nerve by a vascular structure is implicated in the pathogenesis of the disease. However, recent reports have highlighted the advantages of the endoscope in visualizing structures within the cerebellopontine angle. Additional research, using the endoscope to supplement the microscopic procedure, has demonstrated improved localization of neurovascular conflicts. In this report we present the results of our series utilizing a fully endoscopic vascular decompression (EVD) technique, and compare these results to those published for microvascular decompression. From September 1999 until October 2004, 255 patients underwent endoscopic vascular decompression of the trigeminal nerve. These patients' records were retrospectively reviewed, and additional data from follow-up visits were collected and analyzed to ascertain success rates and review the incidence of complications. From a total of 255 patients who underwent EVD of the trigeminal nerve we noted an initial, complete, postoperative success rate in 95 % of patients. Initial, being defined as within the first 3 months postoperative, and "complete" being judged if the patient reported 98 % relief of pain postoperatively without the need for medication (Barker's classification). Additionally, we documented a 93 % complete success rate for 118 patients who completed at least a three-year follow-up period. Complication rates were compared to those reported for MVD. There were no serious complications or mortality in this series. We conclude that EVD is a safe and effective method to remove neurovascular conflicts related to the trigeminal nerve. The results of this series demonstrate an improved rate of trigeminal neuralgia relief with EVD when compared to MVD, a lower incidence of complications and a better outcome.