We report that GTP cyclohydrolase (GCH1), the rate-limiting enzyme for tetrahydrobiopterin (BH4) synthesis, is a key modulator of peripheral neuropathic and inflammatory pain. BH4 is an essential cofactor for catecholamine, serotonin and nitric oxide production. After axonal injury, concentrations of BH4 rose in primary sensory neurons, owing to upregulation of GCH1. After peripheral inflammation, BH4 also increased in dorsal root ganglia (DRGs), owing to enhanced GCH1 enzyme activity. Inhibiting this de novo BH4 synthesis in rats attenuated neuropathic and inflammatory pain and prevented nerve injury–evoked excess nitric oxide production in the DRG, whereas administering BH4 intrathecally exacerbated pain. In humans, a haplotype of the GCH1 gene (population frequency 15.4%) was significantly associated with less pain following diskectomy for persistent radicular low back pain. Healthy individuals homozygous for this haplotype exhibited reduced experimental pain sensitivity, and forskolin-stimulated immortalized leukocytes from haplotype carriers upregulated GCH1 less than did controls. BH4 is therefore an intrinsic regulator of pain sensitivity and chronicity, and the GTP cyclohydrolase haplotype is a marker for these traits.

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We acknowledge R. Keller, co-principal investigator of the Maine Lumbar Spine Study, for his support and advice; A. Häussler, P. Kahler, I.N. Grundei, A. Kirchhof, A. Bollettino, H. Hipp and C. McKnight for technical assistance; S. Niemann and A. Kingman for genetic and biostatistical advice; E.R. Werner for biochemical advice and C. Hesslinger (Pharmazentrum Frankfurt, J.W. Goethe-University, Frankfurt, Germany; current affiliation: ALTANA Pharma AG, Konstanz, Germany) for the GTP cyclohydrolase antibody. The work was supported by grants from the US National Institutes of Health (NS039518 and NS038253, C.J.W.; NS052623, M.C.; Z01 DE00366, M.B.M.; Z01 AA000301, D.G.; DE16558, DE07509 and NS045685, L.D. and W.M.), the Deutsche Forschungsgemeinschaft (DFG322_2-1, S.F.B.; 553/C6, I.T. and G.G.), the Bundesministerium für Bildung und Forschung (BMBF 01, E.M.; 0511, G.G.) and the Dr. Robert Pfleger Foundation (I.T.).

Author information

Author notes

    • Irmgard Tegeder
    •  & Michael Costigan

    These authors contributed equally to this work.


  1. Neural Plasticity Research Group, Department of Anesthesia and Critical Care, Massachusetts General Hospital & Harvard Medical School, 149 13th Street, Room 4309, Charlestown, Massachusetts 02129, USA.

    • Irmgard Tegeder
    • , Michael Costigan
    • , Robert S Griffin
    • , Joachim Scholz
    • , Andrew Allchorne
    • , Alexander M Binshtok
    •  & Clifford J Woolf
  2. Pharmazentrum Frankfurt, Institut für Klinische Pharmakologie / Zentrum für Arzneimittelforschung, Entwicklung und Sicherheit, Klinikum der Johann Wolfgang Goethe-Universität, Theodor Stern Kai 7, Frankfurt am Main, 60590, Germany.

    • Irmgard Tegeder
    • , Andrea Abele
    • , Helmut Schmidt
    • , Corina Ehnert
    • , Claudiu Marian
    • , Jan Adolph
    • , Jörn Lötsch
    •  & Gerd Geisslinger
  3. Laboratory of Neurogenetics, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Department of Health and Human Services, 5625 Fishers Lane, Room 3S-32, Rockville, Maryland 20852, USA.

    • Inna Belfer
    •  & David Goldman
  4. National Institute of Dental and Craniofacial Research, National Institutes of Health, Department of Health and Human Services, 10 Center Drive, Building 10, Room 3C-405, Bethesda, Maryland 20892, USA.

    • Inna Belfer
    • , Jemiel Nejim
    • , Tianxia Wu
    •  & Mitchell B Max
  5. Center for Neurosensory Disorders, School of Dentistry, 2110 Old Dental Building, CB# 7455 University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599-7455, USA.

    • Luda Diatchenko
    • , Swetha Sama
    •  & William Maixner
  6. University of Florida College of Dentistry, Community Dentistry and Behavioral Science, 1329 SW 16th Street, Gainesville, Florida 32608, USA.

    • Roger B Fillingim
  7. General Medicine Division and the Clinical Epidemiology Unit, Massachusetts General Hospital & Harvard Medical School, 15 Parkman Street, WAC 615, Boston, Massachusetts 02114, USA.

    • Steven J Atlas
  8. Department of Psychiatry, Harvard Medical School, McLean Hospital, 115 Mill Street, Belmont, Massachusetts 02478, USA.

    • William A Carlezon
    •  & Aram Parsegian
  9. Howard Hughes Medical Institute–National Institutes of Health Research Scholars Program, 1 Cloister Court, Building 60, Bethesda, Maryland 20892-1460, USA.

    • Jemiel Nejim


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I.T. and M.C. designed and organized experiments; performed animal studies, expression and function analyses and human screens; analyzed data; generated figures; and wrote the manuscript. R.S.G. contributed to the initial study concept and performed expression profiling and in situ hybridization. A.A. performed in situ hybridization and enzyme and antibody production studies. I.B. conducted human genotyping. H.S. designed and performed LC-MS/MS analyses. C.E. performed electrophysiology. J.N. conducted human lymphocyte studies. J.S. conducted animal studies and wrote the manuscript. C.M. conducted animal studies. T.W. analyzed spine pain data. A.A. studied animal behavior. L.D. analyzed human experimental pain data. A.M.B. performed calcium imaging studies. D.G. devised genotyping approaches and human lymphocyte studies. J.A. conducted haplotype function analysis. S.S. analyzed human experimental pain data. S.J.A. collected and adapted clinical spine data. W.A.C. and A.P. conducted the forced swim test. J.L. analyzed human genetic data and designed haplotype function analyses. R.B.F. and W.M. phenotyped experimental pain cohort and interpreted genetic data. G.G. initiated, organized and supervised analytical studies. M.B.M. initiated, organized and analyzed human studies and wrote the manuscript. C.J.W. initiated and supervised the study, designed experiments, analyzed data and wrote the manuscript.

Competing interests

C.J.W. has an equity holding in a company, Solace Pharma Inc., that is negotiating to license technology from the Massachusetts General Hospital related to the manuscript. All other authors have no competing interests.

Corresponding author

Correspondence to Clifford J Woolf.

Supplementary information

PDF files

  1. 1.

    Supplementary Fig. 1

    Analgesic effects of DAHP in neuropathic pain models.

  2. 2.

    Supplementary Fig. 2

    DAHP is analgesic when delivered intrathecally but has no activity in the forced swim test.

  3. 3.

    Supplementary Fig. 3

    Microarray expression profiles of BH4-related enzymes.

  4. 4.

    Supplementary Fig. 4

    Haplotype block organization of GCH1.

  5. 5.

    Supplementary Table 1

    Demographic data of the Lumbar Root Pain study.

  6. 6.

    Supplementary Table 2

    Locations and allelic frequencies of 15 GCH1 SNPs.

  7. 7.

    Supplementary Table 3

    Primer and probe sequences for 5′ nuclease genotyping of 15 .GCH1 markers

  8. 8.

    Supplementary Table 4

    Associations of experimental pain with the number of copies of the GCH1 pain-protective haplotype.

  9. 9.

    Supplementary Methods

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