The thread that disappeared, Answers from Mr. Lawhern

Q1. Is TN1 and ATN the same medical entity? I understand the difference in symptoms but what I do not understand is why TN1 and ATN are treated with different medicine if both are the same thing (at least the name implies they are the same) yet from what I've read here both are treated differently and TN1 medicine doesn't work on ATN and vice versa.

<Opinion on this varies, but the general trend seems to be that TN1 and TN2 are related forms of pain that present in the same nerve distribution. The two "medical entities" have overlapping symptoms. But increasingly, the designation "Atypical" TN or TN-2 is viewed as a neuropathic condition associated with various forms of physical damage to the nerve, while TN-1 is an inflammation whose precise origins or causes are still not fully known.

Q2. If ATN is very constant, milder pain.... Then why is not considered a neuropathy? I had a neuropathy on my leg before and it was three years of a very specific numb area of my skin that felt weird to touch. I do not recall stabbing pain or a change in pain, it was rather very constant and consistent in symptoms.

<See Q1 above.

Q3. Why is TN1 called true trigeminal neuralgia (I've seen it called like that on some sites), does that mean ATN is rather a symptom of an underlying issue causing the trigeminal nerve to get irritated, while TN1 is a more concrete entity with more specific symptoms and causes?

<Except for the "specific" part, your statement would probably be comfortable for a lot of neurologists. I've talked with many people whose "classic" or typical TN emerged after some form of dental injury, or even after Shingles. TN-1 is a more specific pattern.

Q4. How can you tell the difference between TMJ and ATN? (I understand ATN is a consistent milder pain that can present itself without any of the TN1 stabbing, and TMJ is also a consistent milder pain that can have stabbing pain similar to TN1, so they truly overlap) so what sets them apart? I also know TMJ causes cracking sounds but according to some doctors I've spoken to TMJ not always create cracking noises at the joint. So how do they set them apart? is there any criteria?

<Differential diagnosis between TMJ and ATN can be subtle. Send me an email at ■■■■■■■■■■■■■■■■■■■, and I will send you a long article on how such diagnoses are made and distinguished from one another. It is wise to understand that TMJ is very likely very much over-diagnosed by general dentists who have minimal training in neurology. When you get volleys of lightning strike electric-shock pain which are not sensitive to the position of your jaw, then almost certainly you aren't dealing with TMJ, but with TN1.

Q5. Why do they classify ATN and Trigeminal Neuropathy different? I have seen here that they treat them with the same type of medicine... so why are they different?

<Most likely they aren't different. This distinction seems to be a hold-over from the earlier diagnosis by elimination called "atypical face pain". At one time it was common to put that label on any case of face pain that crossed the center line of the face -- and to imply that the problem was psychological rather than physical. It is now known that bilateral neuralgia and neuropathy are fairly common among face pain patients. But regrettably, some medical authorities who should know better insist on peddling the mythology that bilateral face pain is caused by depression or stress, and is thus somehow less "real".

I wanted to ask some other questions.

Based on your answers I have concluded that ATN and TN1 affect both the same nerve, but the origin is different, TN1 is inflammation or a vein pressing against the nerve all the way in the ganglia, while ATN might be caused by things like virus or trauma.

The way I picture the trigeminal nerve it's sort of a tree with three big branches, and those three branches have little branches where the leaves grow.

I wanted to ask, TN1 pain is electric stabbing shocks that affects a branch or two of the nerve and all of its little branches... Do patients tend to feel the pain coming all the way from inside their heads/brains hitting them on the face all over the affected branch and its little terminal branches? Or is it more a stabbing localized on a specific part of the nerve?

Because I am under the impression that a lot of ATN patients' pain is rather on the terminal branches of the nerve IE(many complain of pain exclusively on one tooth, on the upper lip, around the eye.) rather than complaining about the pain extending all the way through the nerve and its little branches all over.

Would that mean for many ATN patients the pain is not on the entire branch but on some of the little end branches? My issue for example is around the infraorbital nerve and around the upper/lower lip and tongue. I have not felt any pain coming from inside my brain. I do feel a very minor shock around the cheek but it;s very mild.


Last year I had labyrinthitis, the terrible non-stop vertigo and nausea that lasted a few months led me to an increased state of anxiety and panic attacks from which I have not fully recovered. When I was starting to feel better I found that my lower and upper lip started to burn. I was also left with a weaker eye that feels droopy but its not and at times it gets a tad blurry. (all on the left side of my head)

My doctor at the time told me that such condition is caused by several things including one of the herpes simplex virus (not sure which one) reactivating on the ganglia and causing the nerve to get inflamed.

Do you think that the virus once reactivated could have affected my trigeminal ganglia and perhaps the optic nerve causing the neuropathy and weaker eye I have today? I believe it's the Herpes simplex 1 if I am not mistaken. I did get a high resolution MRI of the area and they found nothing (no tumors, no MS, no blockages)

The other possible explanation I have is the bruxism I had for all those months while I recovered from my inner ear, I wonder if the bruxism left to some form of TMJ (I did develop pain on that joint) and now I have developed some form of myofascial issue on the muscles of the face, causing the branches of the V2 and V3 to be irritated, which apparently happens to TMJ patients.

Could there be any relation?

I also wanted to mention that I belong to a support group for people with labyrinthitis and two people so far told me they developed facial pain after they got labyrinthitis!