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Summary: Objective: To investigate long‐term seizure outcomes in patients with hypothalamic hamartoma (HH) following stereotactic radiofrequency thermocoagulation (SRT). Methods: A total of 131 patients with HH who underwent SRT and were followed for at least three years after the last SRT were enrolled. Seizure outcomes were evaluated for gelastic seizures (GS) and other types of seizures (nGS) separately using the International League Against Epilepsy classification. Classes 1 and 2 were considered seizure‐free. Kaplan‐Meier survival analyses were used to estimate the proportion remaining seizure‐free after the first and last SRTs. Risk factors relating to outcomes were analyzed by log‐rank tests and a multivariate Cox proportional hazards model. Results: Reoperation was performed in 34 patients (26.2%). Median total follow‐up was 61 (range, 36–202) months. Seizure freedom was obtained in 116 patients (88.6%) for GS and 85 of 108 patients (78.7%) for nGS at the last follow‐up. Mean GS‐free survival times improved from after the first (64.1 [95%CI 57.3–70.9] months) to after the last SRT (80.2 [95%CI 75.7–84.8] months). About 90% of GS recurrences after the first SRT were found within 6 months, though a few patients recurred more than 2 years after the first SRT. On the other hand, mean nGS‐free survival times after the first and last SRTs were not different between after the first SRT (84.4 [95%CI 73.0–90.7] months) and after the last SRT (83.1 [95%CI 74.1–92.0] months). There was no factor related to GS outcomes, but the significant factor for nGS‐free survival after the last SRT was multiple previous treatments (p=0.01, hazard ratio=15.65, 95%CI 1.79–137.16). Significance: The last SRT was almost equivalent to achieving complete disconnection of HHs from the hypothalamus according to our strategy. Considering the epileptogenic network, GS outcomes depend on complete disconnection, whereas nGS outcomes are not affected by surgical factors but independency of secondary epileptogenesis. [ABSTRACT FROM AUTHOR]