Tyramine and MAOIs: Foods to Avoid with These Antidepressants

When you're taking an MAOI antidepressant, what you eat isn't just about nutrition-it can be a matter of safety. Monoamine Oxidase Inhibitors (MAOIs) like phenelzine, tranylcypromine, and isocarboxazid are powerful tools for treating depression, especially when other medications haven't worked. But they come with a hidden risk: tyramine, a naturally occurring compound in certain foods. If you don't know which foods to avoid, you could trigger a sudden, dangerous spike in blood pressure-even from something as simple as a slice of cheese or a spoonful of soy sauce.

Why Tyramine Is Dangerous with MAOIs

Your body normally breaks down tyramine using an enzyme called monoamine oxidase-A (MAO-A), mostly in the gut and liver. MAOIs block this enzyme. Without it, tyramine builds up in your bloodstream. That’s not a problem for most people, but for someone on an MAOI, it’s a red flag.

When tyramine floods your system, it forces your nerve cells to release large amounts of norepinephrine, a chemical that tightens blood vessels and speeds up your heart. The result? A rapid, severe rise in blood pressure-sometimes over 180/120 mmHg. This is called a hypertensive crisis. Symptoms include pounding headache, blurred vision, chest pain, nausea, and sweating. In rare cases, it can lead to stroke or death.

The risk isn’t theoretical. Studies show that just 10 to 25 milligrams of tyramine can trigger this reaction in people on MAOIs. For context, one ounce of salami has about 50 mg. A tablespoon of soy sauce? Around 15 mg. You don’t need to eat a lot to cross the danger line.

Which Foods Are High in Tyramine?

Tyramine doesn’t show up in fresh foods. It forms when proteins break down over time-through aging, fermentation, or spoilage. That’s why it’s common in preserved, aged, or fermented products.

• Aged cheeses: Cheddar, Swiss, blue cheese, Parmesan, and other hard, aged cheeses can contain 50 to 400 mg of tyramine per 100 grams. Fresh cheeses like mozzarella, cottage cheese, and cream cheese are safe-under 10 mg per serving.
• Dried or cured meats: Salami, pepperoni, summer sausage, and other air-dried or fermented meats often have 50-100 mg per ounce. Fresh, unprocessed meats like chicken, beef, or fish are fine.
• Fermented soy products: Soy sauce, miso, tempeh, and fermented bean curd are high-risk. Traditional soy sauce can have up to 500 mg per 100 ml, but most commercial brands now contain around 30 mg. Still, even that much can add up if you're eating multiple servings.
• Fermented or pickled foods: Sauerkraut, kimchi, pickled herring, and certain pickles contain significant tyramine. Avoid them unless labeled as fresh or unpasteurized.
• Overripe fruits: Bananas, avocados, and figs become riskier as they ripen. A ripe avocado has about 0.5-3 mg per 100 grams, but if it’s mushy or brown-spotted, levels can jump to 10 mg or more.
• Tap beer and draft beer: These can contain 10-30 mg of tyramine per 100 ml due to natural fermentation. Bottled or canned beer is usually safe, but check labels. Wine (especially Chianti) is generally okay in moderation-around 10-20 mg per 100 ml. Distilled spirits like vodka, whiskey, or gin are low-risk.
• Yeast extracts: Marmite, Vegemite, and other concentrated yeast spreads are very high in tyramine. Skip them entirely.

What’s Safe to Eat?

You don’t need to go on a starvation diet. Most fresh, unprocessed foods are perfectly safe:

• Fresh meat, poultry, fish, and eggs
• Fresh fruits and vegetables (except overripe bananas, avocados, figs)
• Most dairy products (milk, yogurt, fresh cheese, butter)
• Whole grains, pasta, rice, bread (unless it’s sourdough made with wild yeast)
• Most bottled or canned beverages, including coffee and tea

The key is freshness. If it’s been sitting around for days or fermented, it’s risky. When in doubt, ask: Did this food age, ferment, or spoil? If yes, avoid it.

Not All MAOIs Are the Same

The old rule-“avoid everything”-doesn’t apply to everyone anymore. Newer forms of MAOIs have changed the game.

The transdermal selegiline patch (Emsam) delivers the drug through the skin, bypassing the gut where tyramine is usually broken down. At the lowest dose (6 mg/24 hours), you don’t need to restrict your diet at all. Even at 9 mg/24 hours, restrictions are lighter than with older pills. Only at 12 mg/24 hours do dietary limits kick in again.

Moclobemide is another option. It’s a reversible MAOI, meaning it doesn’t permanently block the enzyme. If tyramine shows up, the enzyme can still do its job. That’s why it’s used widely in Europe and carries far fewer dietary restrictions.

So if you’re considering an MAOI, talk to your doctor about which one fits your lifestyle. For many, Emsam is a game-changer.

Other Hidden Risks

Food isn’t the only danger. Many over-the-counter and prescription drugs can interact with MAOIs, sometimes just as dangerously.

• Decongestants: Pseudoephedrine and phenylephrine (found in cold and allergy meds) can cause severe blood pressure spikes. Use saline sprays instead.
• Pain relievers: Some cold medicines contain dextromethorphan or meperidine. Avoid them. Stick to plain acetaminophen.
• Herbal supplements: St. John’s wort, ginseng, and L-tryptophan can increase serotonin levels and trigger serotonin syndrome when mixed with MAOIs.
• Other antidepressants: Never start an SSRI like sertraline or fluoxetine within 14 days of stopping an MAOI. The combination can cause serotonin syndrome-a potentially fatal condition with fever, confusion, muscle rigidity, and seizures.

Always tell every doctor, dentist, or pharmacist you see that you’re on an MAOI. Even a simple antibiotic or anesthesia can interact.

How Long Do Restrictions Last?

MAOIs don’t leave your system quickly. Irreversible MAOIs bind to enzymes for weeks. Even after you stop taking the pill, your body needs 2 to 4 weeks to make new enzymes.

That means you must keep avoiding high-tyramine foods for at least two weeks after your last dose. Some doctors recommend waiting four weeks to be safe. Don’t assume you’re cleared just because you feel better.

If you’re switching to another antidepressant, the 14-day washout period is non-negotiable. There are documented cases of death when people skipped this step.

What to Do If You Accidentally Eat Something Risky

If you eat something high in tyramine-say, a slice of blue cheese or a sandwich with salami-and you start feeling a pounding headache, blurred vision, chest tightness, or a racing heart, act fast.

• Call 999 or go to the nearest emergency room immediately.
• Don’t wait to see if it passes. Hypertensive crises can escalate in minutes.
• Bring your medication list with you.

Most hospitals carry drugs like nitroprusside or phentolamine to reverse the crisis. The sooner you get help, the better your outcome.

Modern MAOIs Are Safer Than You Think

MAOIs used to have a scary reputation. But today, they’re prescribed more than ever-especially Emsam. In 2023, nearly 75% of all MAOI prescriptions in the U.S. were for the patch. Why? Because patients can live normally without constant fear of food.

The key isn’t avoiding MAOIs. It’s understanding which one you’re on, knowing exactly what to avoid, and staying informed. Many people on MAOIs live full, active lives. They eat out, travel, and enjoy meals with family-just with a little more awareness.

The American Psychiatric Association says dietary restrictions are still essential for older MAOIs-but they’re significantly reduced for transdermal selegiline. That’s progress.

Final Checklist

Before you start or continue an MAOI, make sure you’ve covered these:

• Know your exact medication and dose.
• Get a printed list of safe and unsafe foods from your doctor or pharmacist.
• Avoid aged, fermented, or spoiled foods.
• Check all OTC meds for decongestants or dextromethorphan.
• Carry an MAOI alert card in your wallet.
• Wait at least 14 days before starting any other antidepressant.
• Continue food restrictions for 2-4 weeks after stopping the MAOI.

Frequently Asked Questions