Treatment of trigeminal neuralgia continues to be challenging. The treatment options include pharmacotherapy, or failing this, surgical options like microvascular decompression (MVD), radiofrequency ablation, pencil beam convolution and Gamma Knife surgery. The authors of this article have presented a series of 54 patients who were treated with Gamma Knife surgery (GMS) for recurrent trigeminal neuralgia after microvascular decompression and other ablative procedures. Seventy-eight percent of patients experienced initial pain relief and 44% maintained long-term pain relief without pain medication. Additionally, GMS after MVD was well tolerated without increased incidence of complications. The authors also report that their long-term outcome in this group was similar to that of patients undergoing GMS as primary treatment. This article provides evidence that GMS provides a safe option for treatment of persistent or recurrent pain after MVD.