Severe pain which cannot be controlled medically is the major factor for which patients seek surgical treatment for trigeminal neuralgia. Patients should be neurologically screened and have an enhanced CT scan prior to surgery in order to exclude a secondary cause for the disease. Peripheral techniques such as cryotherapy and alcohol injections give short-term pain relief but have few complications. The most popular operation, radiofrequency thermocoagulation in the Gasserian ganglion, has a mean recurrence of 3 years, but leaves patients with extensive sensory loss. Microvascular decompression and partial rhizotomy are major neurosurgical procedures that have a low recurrence rate but carry a risk of death and serious morbidity. Patients should be more involved in the choice of surgery.