Stereotactic radiosurgery is an increasingly used and the least invasive surgical option for patients with medically refractory trigeminal neuralgia (TN). The authors began use of this technique at our center in 1992 and have evaluated outcomes serially. Independently acquired data from 220 patients with idiopathic TN that had Gamma Knife radiosurgery was reviewed. The median radiosurgery dose was 80 Gy with a range of 60 to 90 Gy. Most patients had features of typical TN, although 16 (7.3%) described additional atypical features. One hundred thirty-five patients (61.4%) had prior surgery. Patients were followed to a maximum of 6.5 years (median, 2 years). Complete or partial pain relief was achieved in 85.6% of patients at 1 year. Complete pain relief was achieved in 64.9 % of patients at 6 months, 70.3% at 1 year, and 75.4% patients at 33 months. Patients with an atypical pain component had a lower rate of achieving pain relief (p= 0.025). Due to recurrences, 55.8% of patients had complete or partial pain relief at 5 years. The absence of preoperative sensory disturbance or prior surgery correlated with an increased proportion of patients in complete or partial pain relief over time. Ten percent of patients developed new or increased subjective facial paresthesia or facial numbness. Radiosurgery for idiopathic TN was safe and effective, and provided benefit to a patient population with a high frequency of prior surgical intervention. It is an important addition to the surgical armamentarium for TN.