This chapter reviews the neurosurgical elements of classic trigeminal neuralgia, the most prevalent neurovascular compression. The history of microvascular decompression, the pathophysiology of neuralgia, and the particular anatomical relationships between the trigeminal root and the arteries and veins of the cerebellopontine angle are presented comprehensively. The recommended treatment for drug-resistant classic trigeminal neuralgia is the microvascular decompression of the trigeminal root in the cerebellopontine angle. The surgical steps of treatment and the approach to be taken for the different surgical types of microvascular compression, as well as the results, outcomes, and complications, are described. For certain selected patients, alternative neurosurgical treatments such as stereotactic radiosurgery and percutaneous procedures are advised. Despite the fact that all trigeminal neuralgia therapies are highly effective, each one has unique characteristics that require the neurosurgeon to choose carefully the right candidates.