Objective To compare the efficacies of esmolol and urapidial in improving brain beat during microvascular decompression surgery for hemifacial spasm. Methods A total of 226 patients scheduled for microvascular decompression surgery received general anesthesia with controlled blood pressure,with the mean arterial blood pressure (MAP) being 55-65 mmHg (1 mmHg=0.133 kPa) and the bispectral index being 40-60. Thirty-two of the 226 patients who developed brain beat were randomly assigned to 3 groups: group A (esmolol, n=11), B (urapidial, n=11) and C (isotonic NaCl, n=10), receiving intravenous injection of esmolol 10 mg, urapidial 5 mg and isotonic NaCl 2 mL, respectively. The heart rate (HR), mean arterial pressure (MAP) and cardiac output (CO) at T0 (before injection),T1(1 min after injection), T2 (5 min after injection), T3 (10 min after injection), T4 (30 min after injection), operating time under microscope, and improvement of brain beat were observed. Results There were no significant differences in HR, MAP or CO at T0 time between the three groups. HR and CO were significantly decreased in group A compared with those in group C at all time points(P<0.01); MAP values were similar between group A and group C. HR, MAP and CO were similar at different time points in group C. The improvement rate of group A was significantly higher than those of group B and group C(P<0.01). The operating time under microscope in group A was (18±4) min, which was significantly shorter than those in group B ([28±6] min) and group C ([29±5] min). Conclusion Esmolol can notably improve the brain beat during microvascular decompression surgery for hemifacial spasm.