Trigeminal neuralgia is unilateral recurrent episodes of sharp pain. Failing medical treatments require vascular decompression. Complications of the surgery include local ischemia and damage or irritation of the cranial nerve. Neurophysiological intraoperative monitoring (IOM) can be used to identify functional changes that can result in minimizing such complications. Changes of IOM signals can alert the surgeon to reverse course in order to preserve function. IOM changes can be of technical, physiological, pharmacological, positional, or surgical origin. Proper and timely management of such changes may prevent postoperative neurological deficits.