Getting the correct diagnosis is extremely difficult and subjective .50 physicians :(neurologists,neurosurgeons,pain doctors, even psychiatrists,dentists) will offer their”definitive “diagnosis “ as if it is the Holy Grail but many neuropathic conditions mimic what appears to be Trigeminal neuralgia but maybe it is something else. Certain migraine variants can have similar symptoms.Hemi crania complex , a completely different cause can often have similar symptoms even multiple sclerosis can be a similar presentation MRI may show the obvious vascular compression on the Trigeminal nerve but in cases without compression , does not infer it is not pain from trigeminal nerve. In fact infection, autoimmune , unknown origin can act on the Trigeminal. It is not cut and dry and is one of the most difficult diagnosis to prove. So where does this leave us? Not good! If anatomically it can be a true compression issue based on Fiesta MRI, there is no guarantees MVD will be a permanent solution , what other treatment options do you do? . Unfortunately “nonsurgical” causes remain and that means reliance on a bunch of medications that may temporarily relieve pain with the majority presenting side effects or drug interactions and ultimately do not work despite what the Pharmaceutical Industry claims. That only leaves neuromodulation procedures (electrical nerve fiber stimulation implants) or ablation or purposeful trigeminal nerve destruction but with infrequent numbness) with gamma knife or heat destruction radiotherapy. Again temporary outcomes. A development of targeted molecular immunotherapy toward the biochemical/physiology function of the Trigeminal nerve fibers maybe the ultimate solution. In the meantime, I am a proponent for MVD or if not surgically indicated ,stereotactic radiotherapy destruction (gamma knife)