Pulsatile tinnitus, characterized by rhythmic sounds that are often in sync with the patient’s heartbeat, can be a distressing condition with various underlying causes. Effective treatment requires a comprehensive understanding of these causes, which may include vascular anomalies, structural abnormalities, or increased intracranial pressure. Both surgical and endovascular approaches offer promising solutions for managing this condition. Explore the key surgical and endovascular treatment options available for pulsatile tinnitus, highlighting their mechanisms, effectiveness, and the clinical scenarios in which they are most applicable.