Primary hyperparathyroidism (pHPT) is a potentially debilitating endocrine disorder for which surgery remains the only definitive cure. Over the past two decades, surgical approaches have evolved with the advent of image-guided, minimally invasive parathyroidectomy, particularly in patients with single-gland disease identified on preoperative imaging. As a result, preoperative imaging has become a critical standard to enable focused surgical intervention. Despite the growing promotion of 18F-fluorocholine PET/CT as the first-line imaging in this setting, state-of-the-art parathyroid scintigraphy remains a valuable and clinically relevant tool. While 18F-fluorocholine PET/CT is increasingly used with promising results, the risk of underestimating multiglandular disease—especially in cases of normocalcemic hyperparathyroidism—should not be overlooked.