Classic idiopathic trigeminal neuralgia is characterized by sharp unilateral shooting pain in the distribution of one or more branches of the trigeminal nerve. It involves a diagnosis of exclusion. Initially, therapy consists of medical therapy, preferably with carbamazepine or oxcarbazepine. For patients refractory to medical therapy, microvascular decompression of the trigeminal nerve provides the best long-term outcomes, at a relatively low complication risk. In case of surgical contraindications, there are other options: radiosurgery or a neurodestructive procedure of the trigeminal ganglion. Short-term outcomes after neurodestructive therapy are good, however effects diminish over time. Every patient with idiopathic trigeminal neuralgia in whom medical therapy has failed, should be counselled at an experienced centre in which neurosurgical treatment is available.