Low Histamine Diet for Managing Histamine Intolerance
A low-histamine diet is the gold standard treatment for histamine intolerance, with fermented foods being unanimously excluded across all evidence-based dietary approaches. 1
Understanding Histamine Intolerance
Histamine intolerance is primarily caused by a deficiency in the diamine oxidase (DAO) enzyme at the intestinal level, which leads to reduced histamine degradation in the gut and subsequent accumulation in plasma 2. This results in multiple clinical manifestations including:
- Skin symptoms: urticaria, flushing, itching
- Gastrointestinal symptoms: diarrhea, abdominal bloating, cramps
- Neurological symptoms: headaches
- Respiratory symptoms: dyspnea
- Cardiovascular symptoms: tachycardia, hypotension
Unlike true food allergies which are IgE-mediated, histamine intolerance is a non-immunological response to ingested histamine 1. Skin-prick testing and specific IgE to food allergens are typically negative in these patients 3.
Recommended Low-Histamine Diet
The dietary management of histamine intolerance involves following a low-histamine diet. Key recommendations include:
Foods to Avoid (High in Histamine):
- Fermented foods (unanimously excluded in all diets) 4
- Aged cheeses
- Fish (especially if not fresh)
- Hard cured sausages
- Pickled cabbage
- Alcoholic beverages, particularly wine and beer
- Citrus fruits and bananas (contain putrescine which may interfere with histamine degradation) 4
Implementation Strategy:
- Follow the diet strictly for 4 weeks as an initial trial
- Monitor and document symptom improvement
- Gradually reintroduce foods to identify specific triggers
- Maintain long-term avoidance of problematic foods
Supplementary Treatments
While the low-histamine diet is the primary intervention, additional treatments may include:
Pharmacological Support:
- H1 receptor antihistamines: Can be increased to 2-4 times the standard dose; non-sedating options are generally preferred 5
- H2 receptor antihistamines: Useful for gastrointestinal symptoms and can help H1 antihistamines attenuate cardiovascular symptoms 5
- DAO enzyme supplementation: May be considered as subsidiary treatment for individuals with intestinal DAO deficiency 1
- Cromolyn sodium: Can reduce abdominal bloating, diarrhea, and cramps 5
Efficacy of Treatment
Research shows significant improvement in symptoms with a low-histamine diet:
- In one study, 57 out of 100 patients showed considerable improvement after 4 weeks on a histamine-free diet, with 15 achieving total remission 6
- Another study demonstrated that 33 out of 45 patients improved significantly (p < 0.01) after 4 weeks on the diet 3
- The most striking results were observed in food or wine intolerance (80% improvement), bronchial asthma (80%), headache (64%), and urticaria (58%) 6
Important Considerations
Diagnostic Challenges:
- Diagnosing histamine intolerance requires a complex, time-demanding multidisciplinary approach 1
- A good response to a low-histamine diet is considered confirmation of histamine intolerance 1
Potential Pitfalls:
- Great heterogeneity exists among low-histamine diets in the scientific literature 4
- Only 32% of foods excluded in these diets can be explained by high histamine content 4
- Some foods labeled as "histamine-liberators" are excluded despite having low histamine levels, though the mechanism is not fully understood 4
- Overly restrictive diets may lead to nutritional deficiencies; early dietitian involvement is recommended for patients with severe symptoms 5
Monitoring:
- If antihistamines are used, treatment should be conscious and time-limited, with preference for 2nd or 3rd generation H1 antihistamines 1
- For patients with severe symptoms, avoid an overly restrictive diet through early dietitian involvement 5
Current research is underway to better evaluate the efficacy of low-histamine diets and/or DAO supplementation in improving symptoms of histamine intolerance through more rigorously designed clinical trials 2.