Fibromyalgia (FM) is a central chronic pain syndrome with fatigue, sleep disorders, and other symptoms. It has 1–5 % worldwide prevalence, 3:1 female-to-male ratio, and shows correlation with stress. The pathogenic mechanism is unknown, biomarkers are missing, and patient management is extremely difficult due to the lack of resolutive therapies. We developed a pathogenic model of FM based on a thalamocortical loop network that shifts from monostability to bistability for decreasing GABAergic and increasing glutamatergic transmission, leading to the appearance of a high-firing-rate steady state that represents FM altered central pain processing. Here, we propose the hypothesis that the pathogenic GABA/glutamate unbalance could be effectively counteracted by the use of neurosteroid drugs acting as positive allosteric modulators of both synaptic and extrasynaptic GABAA receptors. Our hypothesis is based on evidence suggesting the involvement of large fluctuations of gonadal neurosteroids (notably brain allopregnanolone withdrawal in perimenstrual/peripartum periods) and of adrenocortical hormones (notably cortisol rise during stress activation) in FM pathogenesis and in the regulation of central GABA/glutamate balance. Therefore, our hypothesis provides a link between FM clinical features (such as female prevalence and correlation with stress) and endocrine influences on neurotransmission, suggesting the use of neurosteroid drugs for the treatment of the disease.
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