Histamine-Rich Foods
Foods high in histamine include aged cheeses, fermented products, cured meats, certain fish (especially tuna), pickled vegetables (sauerkraut), alcoholic beverages (particularly wine and beer), and tomatoes. 1, 2
Primary High-Histamine Foods
The following foods consistently contain elevated histamine levels and should be avoided by individuals with histamine intolerance:
Fermented and Aged Products
- Aged cheeses - universally recognized as high-histamine foods across all low-histamine diet protocols 1, 3
- Hard-cured sausages and processed meats - contain significant histamine due to fermentation and aging processes 1, 3
- Pickled cabbage (sauerkraut) and other fermented vegetables 1, 3
Protein Sources
- Fish - particularly histamine-rich, with levels up to 500 mg/kg in certain species like tuna 1, 4
- Shellfish - contains elevated histamine levels 5
Alcoholic Beverages
- Wine (especially red wine) - contains both histamine and alcohol, which competitively inhibits diamine oxidase (the enzyme that degrades histamine) 6
- Beer - another fermented alcoholic beverage with significant histamine content 3
Important Clinical Context
Mechanism of Histamine Intolerance
Histamine intolerance is not IgE-mediated and differs fundamentally from true food allergy 1, 3. The condition results from diminished histamine degradation due to deficiency of diamine oxidase (DAO), the primary enzyme that metabolizes histamine in the jejunal mucosa 6. This is a host-dependent, nonimmune food intolerance involving impaired metabolic capacity 5.
Foods with Interfering Compounds
Beyond direct histamine content, certain foods warrant exclusion due to other biogenic amines:
- Citrus fruits and bananas - contain putrescine, which interferes with histamine degradation by competitively inhibiting DAO enzyme activity 2
- Tomatoes - contain both histamine and other vasoactive amines 4
Variability in Low-Histamine Diets
A critical review of low-histamine diets reveals significant heterogeneity in food exclusion lists across different protocols 2. Only fermented foods are unanimously excluded across all diet protocols 2. The exclusion of only 32% of commonly restricted foods can be directly explained by high histamine content, while others are excluded based on putrescine content or unproven "histamine-liberator" mechanisms 2.
Clinical Pitfalls
Alcohol consumption compounds the problem - alcohol competitively inhibits diamine oxidase, preventing histamine breakdown even from foods with moderate histamine levels 6. Patients must avoid both histamine-rich foods AND alcohol simultaneously for effective symptom control.
Numerous medications also inhibit DAO - clinicians should review medication lists for DAO-blocking drugs when implementing histamine-free diets 6.
Normal meals can contain problematic doses - a single meal may contain 75 mg or more of histamine, sufficient to provoke symptoms in 50% of susceptible individuals, with reactions occurring immediately or delayed up to 24 hours 4.