There is an ongoing controversy on first-line treatment in acromegaly. Although transsphenoidal surgery has always traditionally been considered the first option, the evolution of new medical treatments is now challenging the clinical paradigm. In fact, somatostatin analogs are highly effective, convenient, avoid the growth of tumors or even shrink them, and also have the advantage of preserving normal pituitary function. On the other hand, when successful, neurosurgery has the advantage of eliminating long-term medical treatment and is less expensive. This manuscript discusses the pros and cons of both treatments.