Vascular compression of the trigeminal nerve in the cerebellopontine angle is now generally accepted as the primary source or “trigger” causing trigeminal neuralgia. A clear clinicopathological association exists in the neurovascular relationship. In general, pain in the third division of the trigeminal nerve is caused by rostral compression, pain in the second division is caused by medial or more distant compression, and pain in the first division is caused by caudal compression. This discussion of the surgical technique includes details on patient position, placement of the incision and craniectomy, microsurgical exposure of the supralateral cerebellopontine angle, visualization of the trigeminal nerve and vascular pathological features, microvascular decompression, and wound closure. Nuances of the technique are best learned in the company of a surgeon who has a longer experience with this procedure.