Microvascular decompression (MVD) is a neurosurgical procedure used to treat various neuralgias of the cranial nerves. The clinical presentation, natural history, pathophysiology, and medical management of trigeminal neuralgia, hemifacial spasm, glossopharyngeal neuralgia, and nervus intermedius neuralgia is reviewed. A thorough discussion on the retrosigmoid approach for decompression of cranial nerves is presented, along with newer techniques and controversies on adjuvant therapies and neuromonitoring. The surgical outcomes of MVD are discussed, along with alternative techniques to open MVD.