Histamine Intolerance: Everything You Need To Know Explained in Plain English

[Last Updated 1st June, 2017]

Histamine intolerance is poorly understood in the medical world.

Most health professional are not knowledgeable on the topic, diagnosis is flaky at best, and the condition itself is difficult to treat.

That’s why I’ve created this guide. It’s a comprehensive, research-driven review of histamine intolerance, with a particular emphasis on diet and treatment.

What is histamine? A simple definition

What is histamine? A simple definitionHistamine is a chemical that is both made by the body and found naturally in certain foods.

In the body it’s produced by mast cells (a type of white blood cell) and has a crucial role in our immune system. It’s actually the key mediator in causing the symptoms of allergy, which is why we take antihistamines for allergy relief.

Histamine also occurs in our food as a by-product of the fermentation of Histidine, which is a form of protein. In this context it’s part of a family of chemicals known as Biogenic Amines, which are produced by bacteria during fermentation, storage or decay (1, 2).

While high levels of biogenic amines (such as histamine) can make you feel unwell, the majority of people tolerate the amounts found in a regular diet.

Summary: Histamine is a chemical that has a crucial role in our immune system. It is produced by the body and also found in certain foods.

What is histamine intolerance?

What is histamine intolerance?Approximately 1% of the population experience adverse reactions to what is considered a “normal” level of histamine in food (3).

This increased sensitivity to histamine is called a Histamine Intolerance.

It develops through both increased availability of histamine in the body, and decreased activity of the enzymes that break down histamine and remove it from your system. This “defect” is primarily thought to be caused by previous gastrointestinal disease and/or genetics.

The main histamine enzyme in the gut is Diamine Oxidase (DAO), while other areas like the skin, spinal cord, lungs and other organs rely on an enzyme called Histamine N-Methyltransferase (HNMT) (3).

So an individual with a histamine intolerance will have low levels of DAO or HNMT (or both), which can lead to a build up of excess histamine in their blood plasma.

It’s not unlike those with a FODMAPs intolerance, or those intolerant to caffeine or lactose. These conditions are also the result of enzyme problems.

Histamine levels and testing

Normal levels of plasma histamine range from 0.3–1.0 ng/mL, but anything above this causes problems. For example, a level of 1–2 ng/mL can increase stomach acid secretion and heart rate, while levels of 3–5 ng/mL can cause flushing and headaches (4).

An individual that is histamine-sensitive and then consumes a high histamine meal is likely to get high plasma histamine levels. Unfortunately, there are no common tests to diagnose it, and the skin prick test is fairly new (5).

Therefore it’s important an experienced clinician rules out food allergies before tweaking your diet for histamine intolerance.

Summary: An increased sensitivity to histamine is called a histamine intolerance. It develops through both increased availability of histamine in the body, and decreased activity of the enzymes that break it down. There are no common tests to diagnose this condition.

Signs and symptoms of histamine intolerance

Signs and symptoms of histamine intoleranceWhile symptoms appear allergy-like, they do not involve an IgE-mediated response and therefore are not allergic reactions (hence the term intolerance).

Of course, there is no way to know this until you have ruled out allergy through tests.

The onset and severity of histamine intolerance symptoms vary greatly between individuals, but common complaints are:

  • Flushing and headaches
  • Respiratory problems including asthma, runny or blocked nose
  • Skin conditions likes rashes, dermatitis, hives or eczema
  • Gastro problems such as nausea, reflux, vomiting, abdominal pain, diarrhoea
  • Dizziness, low blood pressure and irregular heartbeat.

Also note that antihistamines may help to relieve symptoms, but only if you do not already follow a low histamine diet (3).

Summary: Symptoms appear allergy-like, but they do not involve IgE antibodies. The only way to be sure is to get tested for allergies.

High histamine foods to limit or avoid

High histamine foods to limit or avoidIf you are histamine intolerant then it makes sense to reduce the amount of histamine you consume.

Unfortunately, it’s difficult to quantify the amount of histamine found in different foods. It it varies greatly according to the type of bacteria, food composition, length of time unrefrigerated and conditions for fermentation (6).

As a general rule, high concentrations of histamine are typically found in fermented foods such as bread (effects of yeast), sauerkraut, wine, beer, processed meat and aged cheese.

In addition to histamine-rich food, there is a theory (untested) that several foods have the capacity to release histamine directly from our white blood cells (7).

This means they could contribute to increased histamine levels, even if that food itself is low histamine.

High histamine foods

There is a lot of conflicting information online and I found many authoritative sites did not provide very comprehensive lists. I’ve summed up the foods that most experts recommend be avoided:

  • Fermented dairy products such as aged cheese, yoghurt and quark
  • Fermented or pickled vegetables
  • Tinned/canned, cured and processed meats
  • Fermented soya products including miso, tempeh and soy sauce
  • Green tea, matcha tea, coffee, cocoa, chocolate
  • All legumes (includes peanuts), and tree nuts (regular nuts)
  • Citrus fruits, raspberries, strawberries, bananas, pineapple, grapes, pears and fruit juice
  • Avocado, eggplant, spinach, olives, tomato and tomato products (ketchup, tomato juice)
  • Vinegar, bouillon and broth
  • Any alcohol
  • Junk foods or drinks that contain artificial colours or flavours.

I strongly recommend you also check out this Histamine Compatibility list (PDF) by the Swiss Interest Group Histamine Intolerance (SIGHI). It ranks the likelihood of foods to cause symptoms on a scale of 0 to 3 as well as other important tips.

Summary: Foods to look out for are either high in histamine, or have the capacity to release histamine from our white blood cells. But as a general rule, fermented foods are the most histamine-rich and should be avoided.

How much histamine is safe for those who are sensitive?

Defining a safe threshold level for those with a histamine intolerance is incredibly difficult (8).

Firstly, sensitivity to bioactive amines varies greatly between individuals. Unlike food allergies, which are triggered at first exposure, it’s the cumulative amount of histamine that causes symptoms. What may trigger headaches in one person may have no effect on the other.

Secondly, certain pharmaceutical drugs inhibit the enzyme DAO from breaking down histamine in the body. This can lead to increased histamine levels over time, especially if they are long-term medications (9).

Some of the more common drugs include alprenolol (for blood pressure) and many forms of antibiotics.

These factors must be accounted for when deciding on individualised dietary changes and how strict they should be. As a general guideline, a limit of 100 mg histamine per kg in foods and of 2 mg histamine per litre in alcoholic beverages has been suggested, although these are likely too generous (10).

Summary: Individual sensitivity to histamine, as well as the impact of certain pharmaceutical drugs can seriously affect plasma histamine levels. Therefore defining a safe threshold is very difficult.

A low histamine diet

A low histamine diet planA low histamine diet is a structured programme that is best done under the supervision of a dietitian specialising in food intolerance.

Once food allergy has been ruled out, the elimination phase involves strictly limiting the amount of histamine you consume for 2-4 weeks. Diet and symptoms must be recorded in your own food diary, which is proven useful in tracking significant improvements and relapses.

The reintroduction phase is next, where you gradually reintroduce histamine-containing foods to determine your tolerance and threshold. It doesn’t need to be done in a particular order, and I generally advise you reintroduce the foods you miss the most first.

Some pointers to keep top of mind:

  • Try to cook most of your own meals during the elimination phase
  • Avoid or limit eating canned foods and ready meals
  • Avoid junk foods- food dyes/artificial colours can be big triggers
  • Keep your kitchen clean
  • Refrigerate vigilantly as histamine forms on food as they spoil.

A low histamine diet plan

Just to give you an idea of what a realistic low histamine day would look like:

Breakfast: Cereal + milk

Lunch: Fresh Spring (Rice-Paper) Rolls. Avoid using meat or veggies on the high histamine list.

Dinner: Pan-seared chicken breast (fresh or thawed rapidly) + roast potato and vegetables (not those on high histamine list)

Snacks: 1 apple or peach; cucumber or carrot sticks + cottage cheese

Drinks: Water, herbal tea




Summary: A low histamine diet requires you to follow a 2-4 week elimination period, followed by a reintroduction period to determine your histamine threshold. A diet and symptom diary is necessary, and it’s strongly recommended you see a specialist dietitian during this entire plan.

Important considerations before you trial a low histamine diet

Significant dietary restrictions can affect nutritional status at any age (11).

Therefore, the risk–benefit ratio must be considered first when contemplating any form of elimination diet. Much like a low FODMAP diet, a low histamine diet excludes multiple nutrient-dense foods that provide health benefits.

This is why it’s recommended you follow a low histamine diet under the supervision of a dietitian specialised in food intolerance.

Not appropriate for young children

Low chemical diets are becoming increasingly popular for young children despite the lack of evidence they help.

A 2013 case-study review of 74 children placed on an elimination diet (for salicylates) found that almost half experienced harmful side-effects, including nutritional deficiencies, food aversion and eating disorders (12).

Growth rate is highest within the first years of life and a failure to meet this potential can have a long-lasting impact on development and later health (13).

Therefore chemical elimination diets are only warranted for young children if there is clear-cut evidence it is helping with symptoms.

Summary: A low histamine diet can be quite restrictive even though it is temporary, so consider your nutrition status before you start. It’s not appropriate for young children.

Supplements for histamine intolerance

Supplements for histamine intoleranceThere is basically one supplement available marketed specifically for histamine intolerance.

It contains DAO isolated from pig kidneys and is designed to supplement the sub-optimal DAO levels of patients with histamine intolerance.

There was one clinical trial that found DAO supplementation helped to reduce the duration of histamine-induced migraines by 30%, but not the intensity nor how often they occur (14). It was reportedly a small study though, and ideally it would be nice to see if the results can be replicated.

The reviews of this particular supplement are interesting, and you can buy it on Amazon here if you want to give it a try (full disclosure: this is an affiliate link). Note that the capsules are labelled vegetarian (as you would expect), but the DAO inside is sourced from pork. Highly misleading labelling.

And as always, please consult with your personal doctor before you decide to try any new supplements.

Vitamin C and vitamin B6

Some researchers believe both vitamin C and vitamin B6 supplementation can be beneficial too.

Both nutrients are required (cofactors) for DAO activity, so in theory they act as antihistamines by supporting the breakdown of histamine (15, 16).

One trial found that 5 mg of vitamin B6 supplementation daily significantly increased DAO activity in pregnant teenagers, but only those deficient in vitamin B6. It didn’t benefit anyone else (17).

That’s the only scientific proof I could find, and study after study shows that vitamin supplements are basically useless unless you have a clinical deficiency. Your money is better spent on foods naturally rich in vitamin B6 and vitamin C.

Note that if you want to give vitamin C supplements a try then it’s best to avoid the form called ascorbic acid. It is typically derived from fermented corn and/or citrus, both not appropriate for histamine intolerance.




Summary: DAO supplementation was shown in one clinical trial to reduce the duration of migraines, but had no effect on frequency or severity of symptoms. In theory a vitamin C and/or vitamin B6 supplement may help too, but this is not supported by any strong evidence.

Probiotics for histamine intolerance

Probiotics for histamine intoleranceProbiotics are microscopic bacteria that we get from fermented foods.

They help to restore and maintain the balance of bacteria in the gut, which is linked to varying aspects of well-being including digestive health… even weight loss.

Fermented foods are not an option for someone with a histamine intolerance, which leaves us with probiotic supplementation. Unfortunately the research is thin.

One study found oral intake of two Bifidobacterium strains supressed factors involved in histamine signalling and production, at least in rats (18).

Another study looked at the effects of several probiotic strains on human mast cells in a laboratory setting. Researchers were able to “turn down the dial” on the immune response and minimise histamine release, especially with two strains of Lactobacillus rhamnosus (19).

It seems that if probiotics were to help, they would be most useful in preventing allergic reactions rather than treating symptoms of histamine intolerance. Nevertheless, if you want to try some just be careful about what strains you use. Some strains of Lactobacillus have been shown to increase histamine content, while other strains decrease it (20, 21).

I suggest this probiotic (Lactobacillus rhamnosus) or this probiotic (Bifidobacterium strains) (full disclosure: these are Amazon affiliate links).

Just note that we don’t know the optimal dosage for this condition, nor the long-term side effects (if any), so always consult with your doctor first.

Summary: Early studies on rodents and in test-tubes have shown that certain probiotic strains may help minimise histamine release. The most effective strains are likely to be Lactobacillus rhamnosus or several Bifidobacterium strains, but there is no guarantee they will help.

This is only a guide…

There are a lot of aspects to consider when treating histamine intolerance, particularly when it comes to diet and nutrition.

While I’m a qualified dietitian, this general advice is no substitute for your personal medical professional that knows your medical history.

That being said, if food allergy has been ruled out, avoiding histamine-rich foods as part of a low histamine diet is the next logical step. Some supplements and probiotics may help, but I would not expect any miracles.

There is also food intolerance to consider, which you can learn more about here.



Histamine Intolerance: The Complete Beginner's Guide

Comments

  1. Gerard Baxter says:

    Hi Joe,

    Do you have any doctors in the NYC area that your recommend for Histamine Intolerance/Mast Cell Disease? I have been searching for many years to find an allergist/doctor who has knowledge/experience in the subject.

    Thanks so much!

    • Hi Gerard,

      Sorry I can’t help you there. Perhaps a doctor in that area can pass you onto someone

    • Dr. Ann Maitland. Search on YouTube. She has a 4 hour webinar on Mast Cell/MCAD.

    • Deborah Peruta says:

      Dr, Anne Maitland! long waiting list. I am waiting to get in. Dr. Afrin recommended her via email (I am reading his book!. It is awesome.

    • Christina C Crionas says:

      Gerard Butler, The experts for Mast Cell decease and Histamine issues are at Mayo Clinic in Rochester, Minnesota or at Harvard University’s Medical Center. also, Dr. Afrin, also in Minnesota, about 60 miles away from Mayo Clinic. Many insurance plans cover Mayo Clinic treatments too. Good luck!

    • Dr. Joseph Butterfield is an allergist-immunologist in Rochester, Minnesota and is affiliated with Mayo Clinic. He received his medical degree from University of Chicago Pritzker School of Medicine and has been in practice for more than 20 years. He is one of 19 doctors at Mayo Clinic who specialize in Allergy & Immunology. Butterfield at the MAYO clinic in Rochester Minnesota if this isn’t too far.

  2. Just to share my first hand experience with histamine intolerance. I had eczema and psoriasis for over a year and was informed that stress could have been the initial trigger. Fortunately I was referred to a dietitian who gave me a Salicylate food guide. I started going on an elimination diet cutting out salt, sauces of any kind and just started eating plain food such as fish soup to start with just a speckle of pepper and small potatoes. I noticed at that time, whenever I added tomato or chilli, my eczema will flare up. I realised then I had to be strict with my diet to let my body recover. I was also taking some zinc tablets as well as antihistamine tablets; but I was taking these even before the elimination diet. I also found a shower cream and moisturiser cream that worked for me. These creams are organic. After a month, my psoriasis and eczema started to clear up; I was able to sleep better which helped me recover further. A doctor who had seen me before I started my diet was unable to give me any further advise and I saw 3 different doctors who gave me the same steroid creams which I found did not do much and which I believe could also thin the skin (not good for when I go out in the sun) so I was quite reluctant to use them and so made my own oatmeal solution; this was before I discovered the creams mentioned above. Anyhow I have fully recovered from my eczema and psoriasis. I get the odd flareups on my hand when I eat some fermented food and some foods like shrimps or overindulge in tomatoes.

  3. Thanks for the article. My naturopath suggested D-Hist, which is also available on Amazon. It has been very helpful with my symptoms.

  4. Mark Alman says:

    Ingesting a probiotic species without knowing the strain can be a hazardous undertaking. I would suggest sticking to the specific strains that have research behind them to back their efficacy. If you suspect you are HIT…do your homework.

  5. I became aware of Histamine Intolerance about a year after having two severe allergic reactions to food and a subsequent diagnosis of Oral Allergy Syndrome. At that point, my system became to reactive that I had broken out in hives almost every time I had eaten for a year, and I was desperate to find something that helped.

    I an severely allergic and avoid the foods I know cause problems but doing so had not helped. I figured I had nothing to lose by trying a low histamine diet. Rather than just following the elimination diet for a few weeks, I followed it for several months until I was certain that I was no longer reacting to any foods. My diet was extremely restricted as I also could not eat fresh fruits and vegetables due to the OAS, but I stuck with it. Eventually, I was able to add some foods that I had been unable to tolerate and also learned to avoid the canned and processed foods that I had favored after my OAS diagnosis.

    Adding probiotics last winter also addressed a long term problem with IBS which my GI had unsuccessfully treated for years. I am very careful about the probiotics and change strains periodically which seems to help. I am bookmarking your article so that I can return to it. It is clear, succinct, and puts together information that I have gathered from various sources over the course of the past 2 years. Thanks.

  6. Coffee according to this site is on the high histamine list and on the low histamine list too – it seems every time i research something on the internet the information i find says one thing then it says the complete opposite in the same article on the same web page written by the same author.

    • Hi Chris, I concur. I specifically searched for coffee and histamine intolerance, saw the first section of the article thought “aha!” then “oh” b/c it states to drink coffee/tea. So, unfortunately, I love coffee but am following an AIP diet so I’ve been weening myself off anyway. I would say if you drink lots of coffee, or even a cup a day, do 1/2 a cup for a week, then a 1/4 and finally just a swallow (I went cold turkey and slept at lunch and 4 hours after work before I went to bed for another 10 hours, it was insane!).

      All you can do is take it out of the diet for a month, note changes, reintroduce and see what happens (or don’t if you’re feeling great and it’s the only change you made). There just isn’t enough concrete information out there, like SIBO which is just now unraveling, histamine intolerance will have more info as studies allow, but my guess is it’s decades away.

      Sorry for the rant, hope that helps!

    • True my mistake coffee should not be in the sample plan.

      Best to avoid, at least during elimination period.

  7. I’ve been dealing with histamine intolerance for several years now. Mostly I handle it OK but every so often it clobbers me. I am allergic to soy, so I’m on the paleo diet. A lot of people on the paleo diet run into this problem. I suppose it doesn’t help any that our bodies are already used to making histamine due to soy. I should add I am incredibly sensitive to soy; I react to contact – including the brightly colored ink on some boxes that contain soy protein. It makes me itchy.

    I didn’t know about the ascorbic acid being high histamine. It explains why I always ended up reacting after taking it in powder form for a few days. I had always thought it was cross contaminated with soy. Now I know.

    Mainly I find if I avoid the high histamine foods for awhile, my system will reset and then I can eat them again..but carefully. For example, if I would eat cheese, spinach, canned pineapple (pineapple, pineapple juice), homemade chocolate (from cocoa powder…it’s more like hot chocolate drink really), mushrooms, etc..I would get clobbered. I think mushrooms are high histamine…? The most recent one gave me a red flushed face from eating tomato, spinach, cinnamon (also high histamine) and pineapple plus beef. So don’t eat the stuff day after day. I think the cinnamon bugs me more than the other stuff, probably due to age.

    I can eat most meats (beef,chicken, duck, pork, fish) OK as long as it’s not soaked in anything. A lot of meats these days are soaked in a solution of “natural flavors”, which I am allergic to. I make a lot of homemade soups and stir-fries. To expand my diet, I added a lot of the Asian veggies to my meals like daikon (giant radish), gobo (burdock root), bitter melon, bok choy….the bok choy yellows quickly so need to eat it while dark green.

    Examine greens when you buy them to make certain they are fresh. Look at broccoli for browning or discoloration. It helps alot.

    I drink tea every day. Tea doesn’t bother me, as long as there are no additives like ” flavors”. I also eat a small amount of beef five days a week to get iron. Doesn’t bother the histamine… But then I do watch what I eat. I really don’t eat any preprocessed food.

    I can eat raisens, yogurt, cheese,nuts, etc….BUT only if I avoid other high histamine food at that time. It’s when I forget that I get clobbered with reactions.

    So what I do eat: carrots, celery, gobo, onions,ginger root, bitter melon, squash, daikon, zuchinni, bananas, bok choy, lettuce, spinach (eat it far apart), winter melon, mushrooms, shatake, asparagus, eggs, fish (fresh or frozen fillets… Look at eyes on whole fresh fish to see how fresh they are), chicken, duck, beef, fresh pork….. I may be forgetting some veggies… Eat bananas daily but other fruit less often .

    Hope this helps.

  8. I very new at this so thank you for all the information 👍👍

  9. I came across your blog here and found it very informative, thank you. My son suffers from allergies to foods and other for many years. We have done the diet elimination and been to dermatologists and allergists and never seem to get anywhere. Skin issues(very bad on scalp) that have been diagnosed as eczema/dermatitis/psoriasis. Also, have made my own homemade cleansers, shampoos and natural products purchased none of which work. He also suffers from Ulcerative Colitis and we are trying hard to find ways to battle this for a more norm life. Any suggestions would be gladly welcomed.

    • Please look up ‘fast track diet’, it has helped many with digestive issues.
      I found it helped me but also giving up gluten and grains and dairy stopped itchy skin.

  10. I think i have histamine intolerence because my face flashes when i eat fermented food, meat, banana, drink coffein ect. But it does not flush when i eat avokado? does that mean i don’t have histamin intolerence or is it possible that you tolerate some types of foods and not others ? I hope someone can help me

    • Please look up ‘fast track diet’, it has helped many with digestive issues.
      I found it helped me but also giving up gluten and grains and dairy stopped itchy skin.

      • I have had histamine intolerance since May 2016. My symptoms have increased. I was wondering if anyone has experienced joint pain and muscle weakness. I have also list 37 lbs and wondering when the weight loss will stop. Thanks

  11. Sheila Henry says:

    I am 71 and have varying degrees of seasonal type symptoms and after a virus that lasted through xmas 2014 to Feb 2015 I went on to have a reaction on my BD in August 2015 when I went for a swim I came out of lake covered in hives I have what is known as cold urticaria and csnmot stand any temperature below 20 cel and if exposed to cold I get hives.In my determined effort to beat this thing that has a grip on me even when I sweat as sweat turns cold and I get hives I have learned that olive oil taken before eating increases DAO enzyme 500 % ,so a tablespoon 3x a day plus magnesium before each meal and a B6 vitamin I am so excited about this and would gladly share with anyone my ecperience with histamine intolerance.

    • Sheila,

      This is all new to me. I am 56 and had 2 viruses a year ago and have been different ever since. I am not gluten free, soy free and msg free but recently have had many migraines and continued brain fog. Waiting for next appointment with Functional Medicine Doctor but have seen acupuncturist a few times and she was shocked at my high histamine reaction. Just started researching and finding out I need to change more with food but I like your idea about the fish oil at meal time and increasing DAO! This is very helpful as well as the magnesium and B6. Is it Magnesium Citrate? There are several kinds. Thanks so much for sharing!!!

      • I’d like to kbiw,uf nagnesium citrate is safe as well being that is with citric acid and citris fruit is a,no no.

        • Soorry for all the misspelled words. Was on cell phone and tried to edit post, vut sure if it’s possible. Just needing to know if using magnesium citrate is safe to use being it is made from citric acid. Thanks

  12. I am looking for a Doctor in eastern NC, grrenville, Raleigh,wilmington area for Histamine Intolerance/Mast Cell Disease? Please help me find one.

  13. San Francisco Bay Area Recommendations??? I am seeking a doctor or nutritionist who can support me with histamine/mast cell.

    I am going insane with insomnia waking up with itching skin, itching nostrils and ears, racing heart. I am now severely underweight. I get extremely fresh meat and eat only above ground veggies. I take prescript-assist, seeking health’s bifido strains. My g.i. Doctor is focused on my leaky gut/sibo which I know will heal the histamine intolerance but my symptoms have gotten worse. I am 5’5″ and currently 103lbs. Also taking holy basil to survive during the day. Too many rabbit holes on the internet. Please help me.

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