While the spring rainfall and other weather patterns can change local allergies year by year, some allergists who study pollen counts were surprised by that high of a jump.
"You got to ask yourself, why? It's not like housing stocks," said Cohn. "Why would a city change? You'd think the flora and fauna wouldn't change."
Nelson had at least one explanation: while most of the weeds that contribute to what people call "fall' allergies actually bloom in late summer, an October in a warmer climate like Greenville resembles the temperatures of August in other parts of the country.
"If they (AAFA) really mean September by 'fall,' that may make more sense, because the ragweed is pollinating more down there," said Nelson. But in August, "the pollen counts in North Carolina and South would not even approach the Midwest counts."
Coming in at 3rd, up from 14th last year, is Little Rock, Ark.
Little Rock can lay claim on many historical movements. The city's area was inhabited by Native American tribes including the Choctaw and Cherokee and later occupied by French traders. In the 20th century the city became famous by the desegregation story of the Little Rock Nine, and the city was home to former President Bill Clinton.
"You're not going to be able to cure allergies or escape them," Waldron said. "If you know what your triggers are, and know how to avoid them, then you can live anywhere comfortably."
Part of knowing your triggers, Waldron said, is to go to an allergist and get tested and that's why AAFA included a ranking by a shortage of allergists.
Since Raleigh is known as the City of Oaks for its many oak trees, residents in the city may face tough allergy symptoms in the spring, as well as living in the AAFA's 4th most-challenging city during the fall.
"Even though we talk about rose fever in the spring, it's not rose," said Cohn. "We talk about hay fever in the fall, it's not hay."
Cohn explained that's because roses and other flowering plants actually don't release pollen into the air for reproduction, unlike oaks and maple trees.
"The flowering trees and grasses send out the pollen on the birds and the bees," said Cohn. "It's the less attractive plants that need to put lots of pollen in the air."
Less attractive to the bees, that is. But the City of Oaks attracts many others. Raleigh-Durham, and nearby Chapel Hill, welcome thousands of students each fall to the 10 colleges and universities in the area.
Jackson, Miss., namesake of Andrew Jackson, can lay claim to the great writer Eudora Welty and a tumultuous past from the civil war and through 1960s Civil Rights struggle. It also ranked 5th on the AAFA's list of challenging places to live with fall allergies.
With a relatively small population of 180,000 for a state capital, but seven large parks and a humid subtropical climate, at least some of its inhabitants are likely to run into allergies.
Waldron has some year-round advice for outdoor allergy sufferers: "Once you come home it's good to remove your shoes and clothes." Changing out of pollen-ridden clothes will ensure the offending irritant doesn't follow you around the house. Then, there's hair care.
"It acts like a mop while it's outside and then you bring it in," said Waldron. Allergy sufferers who don't wash their hair risk accumulating the pollen on their pillow case, making for horrible mornings. "It's a whole mess."