Foods High in Tyramine to Avoid with MAOIs
Individuals taking monoamine oxidase inhibitors (MAOIs) should strictly avoid foods with high tyramine content (>6 mg per serving) to prevent potentially dangerous hypertensive crises.
High-Tyramine Foods to Strictly Avoid
Aged and Fermented Foods
- Aged cheeses 1, 2, 3
- Particularly matured/aged cheddar, blue cheese, and other hard aged varieties
- Concentrated yeast extracts 1
- Marmite and similar products
- Sauerkraut 1, 3
- Broad bean pods (fava beans) 1
- Aged/cured meats 1, 3
- Air-dried sausages
- Salami-type sausages
- Improperly stored or aged meats
- Fermented soy products 3
- Soy sauce (particularly aged varieties)
- Aged liver (especially chicken liver aged more than a few days) 3
Beverages
- Tap beer (especially craft and unpasteurized varieties) 4
- Certain wines (particularly red wines and spontaneously fermented varieties) 4
Moderate Risk Foods (Consume with Caution)
- Fresh cheeses in moderate amounts (cottage cheese, cream cheese, processed cheese)
- Most alcoholic beverages in moderation 1
- Note: Chianti wine consumed in moderation appears safe 1
- Pickled foods (consume in small amounts)
Tyramine and MAOIs: Mechanism and Risk
MAOIs block the enzyme monoamine oxidase, which normally breaks down tyramine. When tyramine accumulates:
- It causes release of stored norepinephrine
- This leads to potentially dangerous blood pressure elevation
- This reaction is known as the "cheese effect" or "beer, wine, and cheese effect" 4
Clinical Considerations
Risk Assessment
- Modern food production has significantly reduced tyramine content in many foods 2
- Individual sensitivity to tyramine varies considerably 5
- The threshold for dangerous tyramine consumption is approximately 150 mg 4
Monitoring
- Patients should be educated about warning signs of hypertensive crisis:
- Severe headache
- Neck stiffness
- Palpitations
- Sweating
- Nausea/vomiting
Special Considerations
- Patients taking linezolid (which has MAOI properties) should also avoid tyramine-rich foods 4
- Ozanimod inhibits monoamine oxidase-B and may theoretically interact with tyramine, though clinical evidence of this interaction is lacking 4
Modern Perspective
Recent research suggests that MAOI dietary restrictions may have been overstated in the past 2. However, caution remains warranted for foods with documented high tyramine content. The most dangerous foods are aged cheeses, concentrated yeast extracts, sauerkraut, and improperly stored meats, which should be strictly avoided.
For most patients, a simplified approach focusing on avoiding only the highest-risk foods while allowing moderate consumption of lower-risk items may improve compliance while maintaining safety.