Updated March 27, 2015.

What is Exercise-Induced Anaphylaxis?

Exercise-induced anaphylaxis (EIA) is a form of chronic hives that is caused by exercise. However, people can also experience symptoms of a more severe allergic reaction, called anaphylaxis. Other than hives, people with EIA may have breathing difficulties (shortness of breath, wheezing), circulatory problems (lightheadedness, low blood pressure) and gastrointestinal symptoms (nausea, vomiting and diarrhea).
As its name implies, EIA occurs as a result of exercise.

Exercise can be of any form, including jogging, tennis, swimming, walking, or even strenuous chores such as shoveling snow. Symptoms may start as tiredness, warmth, itching and redness, usually within a few minutes of starting exercise. If exercise continues, hives begin to occur, and may include swelling of the face, lips, eyes and throat (angioedema), and ultimately anaphylaxis.

Cholinergic urticaria is similar to EIA in that exercise, or anything that increases body temperature, triggers hives. However, in EIA, only exercise triggers symptoms, while other increases in body temperature, such as hot showers, will not.

What Causes Exercise-Induced Anaphylaxis?

Like other types of chronic urticaria, EIA's cause is unknown. However, many people have another trigger that, along with exercise, causes the symptoms. These triggers include various medications, a variety of foods, alcohol, cold weather, and menstruation. Typically, either exercise or the specific trigger alone will not cause symptoms.

But, if the person is exposed to the trigger and exercise, then symptoms of EIA may occur.
Medications that have reported to cause EIA include aspirin, ibuprofen and other non-steroidal anti-inflammatory drugs (NSAIDs). It is possible that any medication may trigger EIA when taken before exercising.

A variety of foods, when eaten 24 hours prior to exercising, may cause EIA. However, a person may be able to eat these foods without symptoms if they do not exercise. A long list of foods have been associated with EIA, including cereal grains, seafood, nuts, fruits, vegetables, dairy, and alcohol. Some people with EIA associated with eating, but there is no specific food that triggers the symptoms.

How is Exercise-Induced Anaphylaxis Diagnosed?

Typically, the diagnosis of EIA is based on a person’s history of symptoms that occur only with exercise. If symptoms occur outside of exercise, such as with any increase in body temperature, it is more likely that cholinergic urticaria is the reason for the symptoms.
It is not usually necessary to attempt to trigger symptoms of EIA with having a person exercise under medical supervision. This may be required in special circumstances if the diagnosis is in question. Only a physician skilled in the diagnosis and treatment of anaphylaxis should perform such a test under close medical supervision, with equipment immediately available to treat a potentially life-threatening reaction.

Once a diagnosis of EIA is made, it is important to assess for other triggers as previously mentioned. This may include allergy testing to a variety of foods. A negative skin test to a particular food nearly rules out the possibility of that food as the cause of the EIA. A positive food skin test, especially to a food that was eaten within 24 hours before the person experienced symptoms, may represent the food that caused the reaction.

How is Exercise-Induced Anaphylaxis Treated?

Immediate symptoms of EIA should be treated in much the same way as anaphylaxis from any cause (such as from a food or insect sting allergy). This may require the use of injectable epinephrine, such as with an Epi-Pen or Twin-Ject device.
Prevention of EIA symptoms is the most important goal of treatment. People with EIA should avoid exercising alone, avoid exercising in cold weather, only exercise on an empty stomach, and should avoid eating any causative food (as determined by skin testing) for at least 24 hours before exercise. In addition, avoidance of NSAIDs and alcoholic beverages for 24 hours prior to exercise is also advised. It may be important for women to avoid exercising during their menstrual period.

It would be reasonable for a person with EIA to carry an Epi-Pen and wear a Medic-Alert bracelet describing their medical condition and potential need for injectable epinephrine. An exercising buddy, one who is familiar with how to recognize and treat the person’s EIA, would be ideal.

Want to learn more? Find out the basics of food allergies.

<sub>Sources:

Dice, JP. Physical Urticaria. Immunol Allergy Clin N Am. 2004;24:225-246.

Perkins DN, Keith PK. Food- and Exercise-Induced Anaphylaxis: Importance of History in the Diagnosis. Ann Allergy Asthma Immnuol. 2002;89:15-23.</sub>

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