Epileptogenic hypothalamic hamartomas (HHs) are frequently associated with severe cognitive and psychiatric comorbidities. The anatomical location of these lesions in the hypothalamus and the immediate vicinity of the mammillary bodies (MBs) carries a significant surgical risk. Several surgical approaches have been attempted, with a varying spectrum of complications. Gamma Knife radiosurgery (GKS) is the only surgical technique that has been evaluated in a prospective controlled study. In small HHs of type I-III, GKS has been shown to provide a similar rate of seizure cessation as the ablative techniques (65–70% Engel I & II). The limitation of radiosurgery is that seizure control is delayed for several months. But its major advantage is that it is the least invasive procedure with by far the lowest risk of complications. A prospective trial has shown the absence of mnestic and endocrinological complications, which are observed in a significant number of patients with all other surgical techniques, including LITT. Therefore, for us, GKS is the therapeutic option of choice for all small-sized HHs of type I-II. When the lesion is too large or in case of very severe clinical semiology, there is a rationale to deliberately start with an ablative technique, keeping a safe distance from the MB. If after a few months, seizures recur, GKS of the remnant can be a very good option.