A recent Cochrane systematic review of surgical interventions for trigeminal neuralgia found not a single trial of what is becoming the most popular surgical intervention, namely microvascular decompression (MVD). With an increasing number of anticonvulsant drugs it is likely that patients may not be offered a surgical option for management of their trigeminal neuralgia for many years.Current studies repeat much of what is already in the literature but there is an increasing appreciation of the value of preoperative imaging and the need to be more precise with the diagnosis. The search for prognosticators for good outcomes continues to dominate the literature.Microvascular decompression in correctly diagnosed patients is probably the most effective therapy. However, high-quality prospective studies of MVD in a population that has been well phenotyped and which is assessed pre and postoperatively using psychometrically tested questions, administered at regular intervals by independent observers, are needed to provide clear evidence of its superiority over medical therapies.