Objective <p>To compare the efficacy and safety of middle meningeal artery embolization (MMAE) and burr hole drainage in the treatment of chronic subdural hematoma (CSDH).</p> Methods <p>Patients diagnosed with CSDH who underwent MMAE or surgical treatment were retrospectively recruited to this single-center study. Propensity score matching (PSM) analysis was carried out to compare the efficacy and safety of MMAE and burr hole drainage. Efficacy outcomes included hematoma clearance, cure, recurrence, and re-intervention rates within a 90-day postoperative follow-up period. Safety outcomes included the modified Rankin Scale (mRS) of 0–2 at the 90-day postoperative follow-up, procedure-related complications during hospitalization, and hospital stay length.</p> Results <p>Among the 183 CSDH patients, 34.4% (63 patients) received MMAE and 65.6% (120 patients) underwent burr hole drainage surgery. The MMAE group showed a higher hematoma clearance rate (90.62±8.98% vs. 81.12±18.62%, P=0.005), higher cure rate (63.4% vs. 41.5%, P=0.047), and lower recurrence rate (2.4% vs. 14.6%, P=0.048) after PSM compared to the burr hole group. The re-intervention rates in the MMAE and burr hole groups showed no significant differences (2.4% vs. 7.3%, P=0.305). Safety outcomes favored the MMAE group, with a lower 90-day mRS score (0.34±0.53 vs. 0.73±0.55, P=0.02) and shorter hospital stay (6.41±2.53 days vs. 9.29±3.71 days, P&lt;0.001). Surgery-related adverse events occurred in 4.9% of the MMAE group and 9.7% of the burr hole group patients (P=0.392).</p> Conclusions <p>MMAE was a safe and efficacious alternative procedure for CSDH treatment that showed a reduced recurrence rate.</p>