Syncope is a sudden transient loss of consciousness associated with loss of postural tone, caused by bradycardia, tachycardia, or abnormal autonomic reflexes. Pacing and implantable defibrillators treat but do not cure arrhythmias. Reflex syncope has remained a therapeutic challenge. Remarkably, recent advances in the treatment of the reflex syncopal syndromes are (1) the recognition that many pharmacologic and device-based treatments do not really work, (2) complex subdivisions among the reflex syncope types can be simplified, and (3) effective therapies are often common sense applications of behavioral modifications and physical maneuvers. Many of the treatments have been available for decades and have been supplemented by a renewed interest in the physiologic approach while maintaining a role for evidence-based pharmacologic and device-based therapy. Streamlined workups in dedicated syncope centers may be effective, both economically and therapeutically. In the long term, important advances in syncope are likely to come from the still embryonic field of genetics. Beyond genetic counseling, the greatest benefits lie in the future.