Among the very many diagnostic and treatment options in the management of only very few have proven their efficacy to modern evidence-based medicine standards. For thorough and accurate management, a stepwise diagnostic and treatment approach is recommended.Currently, there is no strong evidence to support either a surgical or medical approach as the best therapy for craniofacial neuralgia. Both surgical and medical therapies are effective for neuralgia. However, factors such as pain relief, recurrence rates, and morbidity and mortality rates should be taken into account when considering which techniques to use. For surgery, peripheral procedures seem to be associated with the highest and earliest recurrence rates. But they can be extremely useful in elderly patients with a limited life span. All procedures performed at the gasserian ganglion level appear to have similar recurrence rates, although it is generally considered highest for glycerol injections. Recurrences do occur after MVD, although from data to date the time interval appears to be much longer. It seems justified from the current evidence to start a patient with trigeminal neuralgia with medical therapy and proceed early with surgical treatment once pain control is poor or side effects of medications are intolerable. It is usually a composite of many parameters that must be individualized in each patient before deciding which surgical procedure to use. More recent investigations have focused mainly on treatment evaluation in long-term follow-up studies and improvement of existing surgical techniques The right timing for surgical intervention is yet to be determined.