Background and aim Trigeminal neuralgia (TN) is a chronic disorder accompanied by recurrent severe pain affecting the face. Many medical regimens are used in the treatment of trigeminal neuralgia. Neurosurgery intervention is the best treatment option, especially with the failure of medical therapy. The aim of the study was to assess the efficacy and outcomes of microvascular decompression for the management of trigeminal neuralgia in Erbil hospitals. Methods This is a prospective clinical study done to treat patients with classical or idiopathic (only patients with neurovascular compression) trigeminal neuralgia by microvascular decompression surgery. It was carried out in Hawler Hospital for cardiac and special surgery and Par Hospital in Erbil city, Kurdistan region, Iraq, from April 2023 to February 2024 on a sample of 21 patients who were diagnosed with trigeminal neuralgia. Results The preoperative mean pain severity score of patients with TN was 8.9±1.2. The means of pain severity score at early postoperative, two weeks postoperative, two months postoperative, six months postoperative, and twelve months postoperative were 2.5, 1.8, 1.3, 0.7, and 0.4, respectively. The preoperative pain severity score of patients with TN was significantly higher and showed a significant decrease postoperatively. The mean pain severity score of patients with TN was significantly reduced twelve months postoperatively. Postoperative complications were present in 14 (66.7%) patients with TN, commonly paresthesia in nine (42.9%), and hearing symptoms in five (23.8%) patients. Conclusion The microvascular decompression is an effective and safe surgical treatment of trigeminal neuralgia.