Histamine, Tyramine and Fermented Foods: Who Needs to Be Careful
Why some fermented foods contain histamine and tyramine, what MAOI medicine labels say about them, and how limited the evidence is for histamine intolerance.
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If you take an MAOI antidepressant, read this first. The US prescribing information for one MAOI, phenelzine, tells patients that certain foods "must be avoided while taking" the medicine "and for two weeks after discontinuing use." [1] Its list includes sauerkraut, pickled herring, dry sausage, cheese (with cottage cheese and cream cheese allowed), yogurt, and beer and wine. [1] Lists differ between medicines and people, so the prescriber or pharmacist decides what applies to you. Do not change a medicine on the strength of this page. The label tells patients to "report promptly the occurrence of headache or other unusual symptoms." [1] For sudden severe symptoms, call 911 in the US.
What the terms mean
Histamine and tyramine are biogenic amines. Some bacteria form them from amino acids during fermentation of cheese, meats, vegetables, soybeans and wine, and they can cause effects "such as migraines." [2] How much a food contains depends on the raw material, the process, how long it is stored and which bacteria are present. [3] So two foods with the same name can differ a lot.Tyramine and MAOI medicines
- What the label says. The phenelzine label lists sauerkraut and yogurt among foods to avoid, and also warns about "foods that may have undergone protein changes by aging, pickling, fermentation, or smoking to improve flavor." [1]
- What a 2022 prescriber review says. Modern food production and hygiene have led to "large reductions of tyramine concentrations in most foodstuffs and beverages," so the risk of a blood pressure rise is considerably reduced, but some caution remains warranted. The authors add that tyramine levels "vary widely within foods of the same category" and that blood pressure responses differ a great deal between people. [4]
- Sauerkraut. A 2023 review states that sauerkraut "has been found to harbor significantly elevated levels of tyramine," and that levels depend strongly on storage time, conditions and starter cultures. [5]
- Not described in the sources we read: tyramine values for kimchi, kefir, kombucha or miso. Ask the prescriber about any fermented food you eat often.
Histamine intolerance
Histamine intolerance is described as an imbalance between histamine taken in and the body's ability to break it down; in healthy people, dietary histamine "can be rapidly detoxified by amine oxidases." [6] Symptoms reported include diarrhea, headache, flushing and urticaria (hives) after histamine-rich food, alcohol, or medicines that release histamine or block the enzyme DAO. [6]| Question | What the sources say | Strength of evidence |
|---|---|---|
| Is histamine intolerance well established? | A 2007 review said double-blind, placebo-controlled provocation studies are still needed. [6] A 2023 review grouped it with intolerances that "still need more evidence and often cause unnecessary dietary restrictions." [7] | Insufficient evidence |
| Can it be diagnosed by a test? | A 2025 review said diagnosis "is hampered by the lack of a validated biomarker." [3] | Limited |
| Which foods does a low-histamine diet exclude? | Lists commonly include fermented vegetables, but "several versions" circulate online and the differences are "largely due to anecdotal evidence." [3] | Insufficient evidence |
| How much histamine is in cheese? | One survey (20 samples per type) found no histamine detected in unripened cheese, an average of 18.05 mg/kg in pasteurized-milk cheese and 59.37 mg/kg in raw-milk cheese, with the highest raw-milk sample at 389.86 mg/kg. [8] | Lab survey, not a health outcome |
Some medicines inhibit DAO; a review table lists examples across antibiotic, blood pressure and other groups. [8] That is a reason to give your pharmacist your full medicine list if you suspect a food reaction, not a reason to stop anything.
Allergy is different
A food intolerance "is different than a food allergy," and allergic reactions can be serious or life-threatening. [9] Trouble breathing or swelling of the face or throat after eating is an emergency: call 911 in the US. See Food allergy basics and emergency signs. Repeated headaches, flushing or stomach upset after meals deserve a clinician's assessment, because other causes need ruling out before foods are cut out.Related
Sauerkraut, Fermented foods safety and home-fermentation risks and Fermented foods and gut health: what trials found.Frequently asked questions
Do all fermented foods contain a lot of tyramine or histamine?
Not necessarily. Levels vary with the food, the process, storage and the bacteria used, [3] and values for several popular ferments are not described in the sources we read.
Can I eat sauerkraut with an MAOI?
Ask the prescriber or pharmacist. The phenelzine label lists sauerkraut among foods to avoid, [1] and a review notes sauerkraut can be high in tyramine. [5]
Is histamine intolerance the same as a food allergy?
No. Intolerance is not an immune reaction, while allergy can be life-threatening. [9]
Does a low-histamine diet work?
Proper evidence not found in the sources we read for a standard diet. Reviews describe the diagnosis as hard and diet lists as inconsistent. [3]
Are yogurt and cheese high in tyramine?
The MAOI label lists yogurt and cheese among foods to avoid (cottage and cream cheese excepted), [1] while a prescriber review says modern production has lowered tyramine in most foods, including many cheeses. [4] Individual products vary, so ask a clinician.
More details: evidence, limits and cautions
The details behind this page: cautions, limits of the evidence and where sources disagree. Open any note to read it.
Who should ask a clinician
References
- US National Library of Medicine, DailyMed. Prescribing information for phenelzine sulfate tablets (an MAOI antidepressant), FDA-approved labeling, section "Warning to the Patient". Read 2026-10-23.
- Marco ML et al. The International Scientific Association for Probiotics and Prebiotics (ISAPP) consensus statement on fermented foods. Nat Rev Gastroenterol Hepatol 2021. PMID 33398112; full text read at PMC7925329. Read 2026-10-23.
- Jackson K et al. Evidence for Dietary Management of Histamine Intolerance. Int J Mol Sci 2025. PMID 41009760; full text read at PMC12470264. Read 2026-10-23.
- Van den Eynde V et al. The Prescriber's Guide to the MAOI Diet: Thinking Through Tyramine Troubles. Psychopharmacol Bull 2022. PMID 35721816. Read 2026-10-23.
- Paul AK et al. Are Fermented Foods Effective against Inflammatory Diseases? Int J Environ Res Public Health 2023. PMID 36767847; full text read at PMC9915096. Read 2026-10-23.
- Maintz L, Novak N. Histamine and histamine intolerance. Am J Clin Nutr 2007. PMID 17490952. Read 2026-10-23.
- Zingone F et al. Myths and Facts about Food Intolerance: A Narrative Review. Nutrients 2023. PMID 38068827. Read 2026-10-23.
- Comas-Baste O et al. Histamine Intolerance: The Current State of the Art. Biomolecules 2020. PMID 32824107; full text read at PMC7463562. Read 2026-10-23.
- MedlinePlus (US National Library of Medicine). Food Allergy. Read 2026-10-23.