Face Pain Info Pages - Part 12

Special Concerns and Problems of Atypical TN Patients

Stef (a co-author of this page) moderates and leads a sizable and active group here at Living with TN for patients who have Atypical (Type 2) Trigeminal Neuralgia. Those patients deal with a number of challenges that even people with the more Typical  (Type 1) TN do not.

ATN is a tougher beast to diagnose clearly than Type 1 TN. MRI isn't as reliable for confirming nerve compression, and symptoms tend to overlap more with other types of neuropathic facial pain. Because of the overlap in symptoms, a number of neurologists I've talked with over the years have suggested that probably a great many patients have been told that they have Temporomandibular Joint Disorder, when what they actually have is ATN or some other form of neuropathic facial pain.

 Because ATN is often 24-7 pain, it can be even more tiring and sleep-depriving -- and therefore an even greater chronic depression and anxiety risk. Of all facial pain patients, perhaps ATN sufferers can benefit the most from supportive therapy, Cognitive Behavior Therapy, and pain management training administered by a psychiatrist or psychologist. Such a professional should understand and reflect in his or her case records that the underlying physical pain is real rather than imagined, but the pain intensity and suffering can be influenced by the patient's approach to coping.

 ATN pain can be misdiagnosed as "Atypical Facial Pain" (AFP).  Although attitudes are definitely changing with regard to limiting the definition and characterizations of AFP, a few physicians still write off any pain that they don't know how to assign to a specific known category, as "psychosomatic." Fortunately, the American Psychiatric Association (APA) is considering a major revision of the category of diagnoses in the Diagnostic and Statistical Manual (DSM) that were once called "somatoform pain disorder."

 ATN is tougher than Typical TN to treat with meds and requires different meds, often in mixtures. When anti-seizure meds such as Tegretol (Carbamazepine) and Trileptal (Oxcarbazepine) are found ineffective, then tricyclic anti-depressants like Amitriptyline may be tried. Although opioids appear to work fairly often for this category of pain, patients and doctors are both affected by prevailing attitudes of fear of addiction.

 Although some neurosurgeons have published data showing good outcomes for ATN by means of MVD, other physicians continue to seem resistant to risking their success statistics. Overall, it is true that surgical management of ATN pain is generally less successful than when the same techniques are applied to "classical" or "Typical” TN pain. One element of surgical technique that has been suggested by a few papers as constructive in improving ATN MVD outcomes is to touch or manipulate the nerve as little as possible.

Reference: Tiril Sandell, M.D., and Per Christian Eide, "Effect of Microvascular Decompression in Trigeminal Neuralgia Patients with or without Constant Pain".  For reprints, you may also e-mail per.kristian.eide@rikshospitalet.no.

Due to the factors discussed above, it can be especially important for patients who have ATN symptoms, to be seen and managed by the best-qualified physicians. In general, very few general practitioners or dentists in general practice will have sufficient training and experience to understand what they are dealing with. Some may not be able to diagnose the disorder at all. A better choice for most ATN patients may be a Board- Certified neurologist, orofacial pain specialist, pain management specialist, or anesthesiologist.

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Face Pain Info Pages - Part 13

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