If you have been in clinical practice for more than 10 years, one of the benefits is that you start to see patterns emerging.
And pattern recognition is something that all clinicians who want to strive for mastery should observe very closely, as it allows you to create bespoke personal plans within the context of common patterns.
This is the nuance of clinical practice, we want to leverage the newest science and evidence, but we must bespoke/personalise it to each patient.
Remember the MAP is NOT the TERRITORY.
Using pattern recognition makes clinical life that much easier with an 80/20 approach.
If we look at the symptoms of fibromyalgia and histamine intolerance/overload.
There is a certain amount of overlap between the two.
Remember, histamine is an excitatory neurotransmitter.
If it builds up within the gut and blood to excessive levels, then it will overstimulate your nervous system.
Remember DAO breaks histamine down outside the cell, in the gut and to some extent in the blood, while HNMT breaks it down inside the cell.
So the question is, could there be a subgroup of fibromyalgia patients where histamine overload is a significant driver or at least a significant contributor to their symptoms?
That is certainly something that I have seen in clinical practice more recently, as I’ve experimented with the use of our NaturoDAO product and Methyl B hero in patients with fibromyalgia.
I find this particularly common in patients with hypermobility and Ehlers-Danlos syndrome, who are far more prone to histamine overload than the average patient or indeed even a patient with fibromyalgia without connective tissue disorder.
There is some research to support this theory.
Note, with these studies the subjects have a diagnosis of fibromyalgia.
However, within this group, it is extremely heterogeneous in terms of the driving factors behind the symptoms. Fibromyalgia is, after all, a simple label.
These patients may simply have a vitamin D deficiency, B12 deficiency, subclinical underactive thyroid, mold toxicity, or undiagnosed Lyme disease, PTSD, the list goes on and on and on.
Thus, the results from the DAO alone in this relatively heterogeneous group are modest, but within the context of that, the researchers discuss a subgroup of patients, who are “responders”.
In other words, they divide patients without histamine issues from those that potentially do have who responded to the DAO.
What we are doing when looking for patients with fibromyalgia and connective tissue disorders, such as hypermobility syndrome or Ehlers-Danlos syndrome, with symptoms that fit, is subgrouping down to make our therapy more likely to be effective.
They conclude: “Qualitatively, the patients assigned to the DAO treatment group had lower scores for fatigue, anxiety, depression, burning and for rumination, magnification, and helplessness.”
Researchers have also used a low histamine release diet to compliment fibromyalgia.
This means they test the patients to see which foods they are releasing histamine against, a form of intolerance testing.
Note, by far, the most common was gluten and dairy, something I routinely ask patients to remove, especially those with HMS/EDS.
And again, a subgroup responded but not all.
A generic low histamine diet (rather than a low histamine release diet) removes food with higher level sof histamine:
- Aged cheeses
- Alcoholic beverages of any kind (especially red wine)
- Avocado
- Dried fruits
- Eggplant/aubergine
- Fermented or aged meats, including salami, sausages, and pepperoni
- Fermented beverages like kombucha and water kefir
- Fermented dairy products (yogurt, kefir, sour cream, buttermilk, cottage, and ricotta cheese)
- Fermented or pickled vegetables (kimchi, sauerkraut, pickles, miso, natto)
- Fish and seafood, particularly tuna or mackerel, especially if left over, smoked, salted, or canned, or not gutted and frozen immediately after harvest. – Ketchup – Soy sauce, tamari, coconut aminos, and liquid aminos
- Spinach
- Leftovers or unfresh food
- Tea (black, green, white, or yerba mate tea)
- Tomatoes
- Vinegars, including apple cider, rice wine, and balsamic
- Yeast products
Reducing these as part of a histamine rebalancing program is useful, at least in the short term. Though it is not like an immune reset diet where it must be 100% removed, a reduction, without complete elimination can still help.
Clinical pattern to look for:
- Patients with diagnosis or symptoms of FIBROMYALGIA AND ideally, with a diagnosis of, or clinical examination consistent with HMS/EDS with widespread symptoms (body, skin, gut, cardiac)
Often, I see patients with HMS/EDS who have lots of physical symptoms and other systemic ones, who would likely fulfill the diagnosis of fibromyalgia, but have never been given a diagnosis – that is a sweet spot for the protocol.
Step 1: Reduce histamine load at the gut level & extracellular level (DAO Support)
The body relies heavily on DAO, to break down histamine in the gut from food before it enters circulation – x1 DAO before food x3 daily
DAO may also remove HISTAMINE in gut made by bacteria AND blood and extracellular spaces – take x1 DAO away from food – This is an emerging idea I am still playing with.
Step 2: Clear histamine inside the cell (methylation support)
Even with optimal DAO activity, histamine is still produced endogenously and released during immune responses.
Once histamine is inside the body and within cells, it is primarily broken down via methylation.
This process relies on histamine N-methyltransferase, which requires adequate methyl donor availability.
This is where many patients fall short.
Suboptimal methylation capacity can result from:
- Low folate intake or poor conversion to active forms from folic acid
- Low vitamin B12
- High stress increasing methyl demand
- Genetic polymorphisms affecting methylation enzymes
When methylation is insufficient, histamine clearance slows, leading to a prolonged inflammatory signal.
This is where targeted support becomes clinically valuable.
Using a well-formulated methylation complex, such as a METHYL B HERO, helps provide the cofactors needed to drive intracellular histamine breakdown.
Not sure what METHYLATION is? Check out this short video
Bringing it together in practice
Focus on patients with HMS/EDS with widespread symptoms that could fit a diagnosis of fibromyalgia or patients with diagnosed fibromyalgia that have clinical features of HMS/EDS.
A simple and effective framework for patients:
1. Lower incoming histamine
- Support DAO activity x1, 3 daily with food and x1-2 daily away from food.
- Reduce high histamine foods if needed and/or gluten/dairy free.
2. Improve internal clearance
- Support methylation with active B vitamins
- Ensure adequate B12, folate, and B6 status via METHYL B HERO