Abstract: Trigeminal neuralgia is characterized by severe, episodic pain in the trigeminal nerve distribution. Medical therapy is the first line treatment. For patients with refractory pain, a variety of procedures including microvascular decompression, percutaneous radiofrequency rhizotomy, percutaneous glycerol rhizotomy, percutaneous balloon compression, and stereotactic radiosurgery are available. We review the literature and suggest that microvascular decompression remains the gold standard operative therapy. For patients with recurrent pain or who are poor operative candidates, percutaneous radiofrequency rhizotomy offers the best pain response rates and has the advantage of being able to selectively target affected trigeminal divisions.