Simultaneous hemifacial spasm (HFS) and trigeminal neuralgia caused by cranial nerve (CN) compression from a tortuous basilar artery (BA) is very rare. We report a case of a 66-year-old man who presented with both HFS and "atypical" trigeminal neuralgia. The patient had a tortuous BA compressing both CN V and VII. The patient underwent microvascular decompression after failing conservative medical management. To the best of our knowledge this is the first reported case of both HFS and "atypical" trigeminal neuralgia that were both successfully treated by surgical intervention. We report the management of this rare combination and review the literature.