Effective management of facial pain syndromes requires a correct clinical diagnosis. The temporal pattern of chronic pain is the most important aspect to be considered. It allows the identification of three groups of patients: (1) those who have paroxysmal pain, (2) those with mixed paroxysmal and constant pain, and (3) those with strictly constant pain. The less is the paroxysmal component, the more likely it seems to be that surgical intervention is useless or even dangerous. In particular, when the diagnosis is atypical facial pain, that is, a diffuse, nonanatomic orofacial pain of unknown pathophysiology, none of the surgical strategies that can cure trigeminal neuralgia should be used. Trigeminal neuralgia patients are often referred to neurosurgeons because of their well-known capability to obtain pain relief through many different procedures such as microvascular decompression, percutaneous balloon microcompression, thermorizotomy, drug injection within the trigeminal cistern and radiosurgery. Since all these procedure can cure patients with typical trigeminal neuralgia, the ideal algorithm of treatment is still under debate. We report on our 20 year-long experience with the surgical treatment of facial pain in general and trigeminal neuralgia in particular. Our treatment algorithm for trigeminal neuralgia is presented. Some ideas to offer a possible surgical help to patients with less typical, medically intractable, chronic facial pain are also given.