Objectives 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 the outcome regarding pain relief, recurrence, and complications with both modalities of treatment. Patients and Methods A randomized prospective study conducted in SaadAlwitry 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 the Barrow Neurological Institute Pain Intensity scale (BNIPI), visual analog scale (VAS) and Brief Pain Inventory Facial (BPI-Facial) scoring systems. In GKR procedure, the trigeminal root entry zone targeted with a radiation dose of 80 Gy. MVD was performed using retro-sigmoid approach. Follow-up period was two years. Results 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, 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).