Microvascular decompression (MVD) remains the only treatment of trigeminal neuralgia that directly addresses the presumed pathogenesis. It is a proven therapy, associated with the longest duration of pain relief while preserving facial sensation. The authors' premise for advocating early MVD is the belief that the disease's natural progression, in the absence of treatment, is toward the development of more atypical features that are refractory to treatment, signifying ongoing neuropathic injury. In an effort to more successfully select candidates for MVD, the authors have incorporated high-resolution magnetic resonance imaging into our preoperative algorithm, since it has proven extremely accurate in defining the neurovascular relations at the trigminal nerve complex. Microvascular decompression can only be recommended when it is performed with low rates of morbidity.