Primary hyperparathyroidism (pHPT) is most effectively treated with surgery, with success largely dependent on precise preoperative localization of hyperfunctioning parathyroid tissue. Among available imaging modalities, PET/CT, utilizing either [18F]fluorocholine (FCH) or [11C]choline, has emerged as a highly sensitive and accurate tool, offering superior diagnostic performance compared to conventional techniques, such as ultrasound (US) and [99mTc]Tc-Sestamibi scintigraphy. Its advantages are particularly evident in challenging cases, including multiglandular disease, ectopic parathyroid glands, or cases with a history of prior surgery. Meta-analyses consistently report patient-based detection rates and positive predictive values of approximately 95%, highlighting the robustness of this technique. Beyond pHPT, choline PET/CT has demonstrated high accuracy in detecting brown tumors and parathyroid carcinoma, expanding its clinical utility. The cost-effectiveness of choline PET/CT is supported by its association with improved surgical outcomes and a reduced need for other imaging and reoperations. Consequently, it is increasingly recommended as a first-line imaging modality in various clinical scenarios, including persistent or recurrent hyperparathyroidism (HPT) and in patients with multiple endocrine neoplasia type 1 (MEN1). Furthermore, quantitative parameters such as SUVmax have shown correlations with disease severity and histopathological findings, providing additional diagnostic value. While occasional false positives can occur, choline PET/CT represents a transformative advancement in the preoperative evaluation and management of hyperparathyroidism.