Abstract : To compare the clinical efficacy of microvascular decompression surgery (MVD) and gamma knife radiosurgery (GKR) as a treatment for patients with primary trigeminal neuralgia (TN) and evaluate outcome regarding pain relief, recurrence, and complications with both modalities of treatment. A randomized prospective study conducted in The Neurosciences Hospital, Baghdad, Iraq. Eighty-four patients with TN from January 2016 to January 2018, 45 patients had GKR while 39 patients treated with MVD. The pain evaluated pre- and post-operatively using Barrow Neurological Institute Pain Intensity scale (BNIPI), visual analog scale (VAS) and Brief Pain Inventory Facial (BPI-Facial) scoring systems. In the GKR procedure, the trigeminal root entry zone targeted with a radiation dose of 80 Gy. MVD was performed using the retro sigmoid approach. The follow-up period was two years. Both groups showed a considerable decrease in BNIPI scores and VAS scores in the postoperative two years follow-up compared with the preoperative scores with a P-value <0.01. However, the pain relief rate was significantly higher in the MVD group (92.3%) compared to that of GKR groups (73.3%) with a P-value of 0.02. Postoperative VAS scores of the MVD group were remarkably lower as compared with those treated with GKR during the same postoperative time. (P=0.01). GKR and MVD offered safe and efficient treatment options. MVD remains the standard surgical method of treatment for patients with TN with better pain relief rate, lesser pain recurrence rate and faster response than GKR