Red Lawhern, What is ATN? everyone says different things and ATN sufferers are just left in the dark taking medication and hoping it gets better magically! (could it be myofascial? vitamins?)

I have issues on my second TN branch, which leaves me with a mild lip tingling, upper front tooth sensitivity, plus some discomfort on my upper-nostril-cheek area.

At times when it gets bad the eye lid (first branch) tingles and the lower canine teeth (third branch) get sensitive.

I have pain when I touch my zygomatic bone, and when I press hard enough it can produce the tongue burning, cheek burning sensation I get sometimes, and my TMJ is sore and hurts when pressed.

At times I also feel tingling on the right side and odd sensations (bilateral) but it's less often.

I saw an ENT, GP, Neurologist, Dental surgeon and none have told me it's TN1 and when I mention ATN they say its rare.

I also have MRI fiesta which shows nothing.

My pain migrates around, it doesn't stay put on one nerve branch affected.

I was checked for TMJ but my jaw doesn't click and I can open my mouth normally.

checking the internet I have found the possibility of myofascial pain syndrome on mastication muscles and indeed have some tension there. I also found that stretching my neck calms my face a bit.... I also found ATN patients here in some posts claiming their muscles are tight. but let's be honest....

The info on ATN all over the net is ridiculously and embarrasingly limited. (burning, tingling sensation on the face which supersedes the stabbing pain of TN1 and that's about it even mayo clinic offers this limited information or well that doesn't do it for me...

I've heard TMJ (which I don't seem to have) intermingles with ATN, others say no it doesn't, I also heard conflicting info such as ATN happens AFTER TN1, basically TN1 morphs into ATN as the nerve gets worse and the pain free intervals become less and less.... I also heard it's a neuropathy, others say it's not a neuropathy, others say it affects their ears but there is no Trigeminal nerve around there, others say there is, others say it's pre-TN, others say Pre-TN no longer is accurate, others say TN2 no longer is accurate but ATN is good, others say ATN is rubbish and useless as a diagnosis... basically it's enough conflicting information to drive a sufferer SUICIDAL!!!

A diagnosis of..... Atypical nerve irritation on the trigeminal nerve DOESN'T DO IT FOR PEOPLE WHO ARE SUFFERING.... it really doesn't!!! It's almost depressing how little information there is on ATN

I was wondering if they have found some connection between ATN (without any stabbing pain) and myofascial issues on the face, or structural problems on the joints of the face. (If so I can at least take a path and investigate to see if that is my cause)

I read ATN people say myofascial therapy help them massively but then on other sites they say such thing doesn't exist!!

Honestly.... it's like the most orphan of all conditions... At least TN1 gets all the press, but ATN is so ignored!

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This is a complex series of questions. I'll try to offer succinct answers for some of them.

(1) Although terminology is still being argued over, "Atypical TN" is increasingly beginning to be seen as a variation on Trigeminal Neuropathy. Any neuropathy is by definition pain that is caused by some form of physical damage to a nerve. But in many cases of face pain, no specific cause or precipitating event can be identified. Such cases are called "idiopathic" as a descriptive term. The term means "of itself" or "without assignable cause".

(2) What we know in spite of this lack of precision, is that achy, burning, constant 24-7 pain called "atypical TN" can develop out of the more recognizable symptoms of TN -- or the other way around! ATN appears to have a different character and might have different causes than TN, but the causes aren't always understood. Damage due to dental procedures or improper administration of anesthetic directly into the Lingual nerve is almost certainly one of those causes. But it's not the only one. Some cases of ATN seem to have more of the character of Central Nervous System pain. We also hear of cases where ATN occurs in association with Fibromyalgia or Lupus or some other systemic disorder.

(3) Some patients do have BOTH TMJ Disorder in the joint of the jaw, and TN in the 5th cranial nerve. The two are not exclusive. But the symptoms of the two disorders can overlap. Complicating this issue is that TMJ is often very imprecisely defined, and few dentists in general practice have much training in assessing neuropathic pain. Thus I believe that TMJ is probably over-diagnosed. I would never accept a TMJ diagnosis without confirmation and a second opinion from a neurologist or craniofacial pain specialist who treats large numbers of facial neuralgia patients.

(4) FIESTA MRI with special magnet weightings is considered the gold standard for imaging of the trigeminal nerve. Best case resolution is about 0.66 millimeters, when images are processed and compared with and without contrast agent. But even this procedure misses significant numbers of arterial or veinous compressions. When a patient has pain dominated by electric-shock stabs, the exploratory phase of a microvascular decompression surgery almost always finds compressions, even if they don't appear in MRI imaging. The usefulness of MRI is to eliminate other problems like benign tumor or AVM as potential causes. But MRI CANNOT eliminate TN as a diagnosis. Anyone who believes MRI can do that is not sufficiently knowledgeable to be treating facial pain patients.

(5) The term "myofascial" pain has a controversial history. Some chiropractors or osteopaths claim to be able to treat pain in the face by "releasing" muscle spasms in the face with direct pressure or massage. I have seen exactly ZERO published trials data that demonstrate any consistent results for such techniques. And I have looked for such data diligently. My best understanding is that this idea is basically incorrect, even though some professionals invest their belief in it.

(6) One thing that a diagnosis of atypical facial neuralgia does for patients: it suggests to a properly trained doctor that the patient needs to be tried on one of the tricyclic antidepressant medications that are known to have a cross-action on neuropathic pain. These include Amitriptyline, Nortriptyline, and about 8-10 others. They are normally used and often effective at dose rates lower than applied against depression itself. Like other meds, they have side effects: sleepliness, dizzyness, word and memory recall problems, and others. If you don't get a positive response to meds in this class, then other combinations of meds can be tried. There are over 70 different combinations that may include Lyrica, Cymbalta, Xanax, NSAIDS, cortico-stereoids, anti-anxiety agents, muscle relaxants, anti-convulsive agents, mild tranquilizers, and otthers. And the only way to find one that works for facial neuropathic pain is trial and observation.

FYI, I wrote most of the Wikipedia article on Atypical TN, and all of the TN Fact Sheet at the US National Institutes for Neurologic Disorder and Stroke (NINDS). I am reasonably knowledgeable of these disorders. But I continue to learn more, after nearly 20 years of reading the medical literature, and talking with what must by now total over 10,000 face pain patients.

Regards and best,

Red Lawhern, Ph.D.

Resident Research Analyst, LWTN

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Generally, yes, treatments for ATN overlap those of neuropathies. Some ATN patients also respond positively to Tegretol or Trileptal. It's unclear exactly why there is overlap, though neuropathy appears to be a complex enough mechanism that a lot of possible effects could be involved.

Anything that raises blood pressure by constricting the walls of blood vessels, is likely to be a trigger for neuropathic pain. Beyond that, I can only say that the chemical you describe seems like a plausible agent. But plausibility isn't always enough to establish cause and effect.

pre-TN as a term in common use seems to be falling out of favor with medical professionals. The main reason for this is that it's known that classic TN can emerge without first presenting as ATN -- and vice versa. That said, the central trend in possibly a majority of patients is for facial pain to include a mixture of the two modalities, possibly preceded by tingling and numbness (called "parasthesia") in the initial stages of development. This mixture seems to have been the basis for the rewording of definitions for TN and ATN, used by the US TN Association and recommended by its Medical Advisory Board. Both forms are recognized as variations of neurologic face pain. But if volleys of electric-shock stabs dominate the patterns of pain, the disorder gets called TN or "Type I" TN, and if constant burning, throbbing pain dominates, it gets called "atypical" or "Type II" TN. Face pain that can be associated with a discrete mechanical cause such as dental injury is now called "trigeminal neuropathy". And TN pain associated with symptoms of MS or tumor may be viewed as "symptomatic" TN.

Regards and best,


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I've talked with patients who had ATN pain in ALL of the teeth on one side, sometimes both sides at different times. There is nerve distribution from the trigeminal system, to all of the teeth. Trigger zones can and do appear in any part of the peripheral distribution of all three branches of the trigeminal nerve, and the triggers may vary from light touch to a breeze to heat or cold. There are no general area charts even for a single individual, in that triggers can shift around on the face.

Sorry I can't offer something neater in the way of explanations. But this is the nature of the beast.

REgards, Red

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