Patients with medically refractory epilepsy, as defined by failure to achieve seizure freedom after adequate trials of 2 antiseizure medications, should be considered for early surgical evaluation. Achieving seizure freedom or meaningful seizure reduction, the goals of surgical treatment, can significantly improve quality of life while decreasing disease-related morbidity and mortality. Preoperative work up and imaging modalities aid in localization of epileptogenic zones that can be targeted in surgery. Resection of a seizure focus yields highest chances of seizure freedom; however, many promising minimally invasive or noninvasive treatment options have been developed in recent years that are closely intertwined with technological advancements and serve as viable alternatives to resection, particularly neuromodulation and ablation procedures. There are also new treatment options being developed and new neuromodulation targets being studied. Surgical treatment options should be thoughtfully selected based on each patient’s individual disease process and preferences.