Background Trigeminal neuralgia (TN) is one of the most severe pain syndromes in clinical medicine, with a prevalence of 4–13 per 100,000 annually. A substantial proportion of patients require surgical intervention following pharmacotherapy failure, yet no unified evidence-based framework exists to guide procedure selection across all ICHD-3 subtypes.Objectives To map the breadth of published evidence for surgical and neuromodulatory TN interventions, synthesize outcome data by procedure and subtype, identify critical evidence gaps, and propose an evidence-based clinical decision algorithm.Eligibility Criteria Adults with ICHD-3-confirmed TN undergoing any surgical or neuromodulatory intervention with a validated pain outcome (BNI, VAS, or NRS) and a minimum three-month follow-up. Eligible designs included systematic reviews, meta-analyses, large clinical series (n ≥ 50), and evidence-based consensus guidelines.Sources of Evidence PubMed/MEDLINE, EMBASE (Ovid), Web of Science, and Cochrane were searched from January 2016 to January 2026. After deduplication and two-stage screening, six sources of evidence met all eligibility criteria.Charting Methods Standardised extraction in duplicate of study design, population, intervention, outcome measure, follow-up, pain-free rate, complication profile, and OCEBM evidence level. Narrative synthesis by procedure category; no meta-analytic pooling.Results Six sources were included: an umbrella review of all surgical procedures (Rapisarda et al. 2023), two MVD-focused systematic reviews and meta-analyses (Rosenzweig et al. 2024; Di Carlo et al. 2022), a prospective SRS cohort series with 15-year follow-up (Régis et al. 2016), a percutaneous procedure synthesis (Chang et al. 2022), and consensus guidelines for peripheral nerve stimulation (Latif et al. 2025). MVD achieves 85–96% initial pain-free rates with the lowest long-term recurrence; SRS carries the most favourable safety profile; and four critical evidence gaps were identified.Conclusions This scoping review maps the surgical evidence landscape across six high-quality included sources, identifies four critical gaps, and proposes a structured seven-step evidence-based clinical decision algorithm for use at the point of surgical referral.