AbstractFish are frequently exposed to paralytic shellfish toxins (PSTs) derived from harmful algal blooms (HAB). PSTs are potent neurotoxins with strong effects on fish at multiple trophic levels. Here, we examine the historical and contemporary mass mortality events combining with the available data on response of fish to PSTs' exposure. The data show that fish are negatively affected by these natural toxins on a recurring basis. Transient effects of PSTs have also been observed in fish and although difficult to quantify, these sublethal effects can affect foraging and predation avoidance. Additionally, the spatiotemporal overlapping of fish spawning and HAB can also be critical for fish survival and fisheries recruitment. Exposure of fish in their early life stages to dissolved toxins in the water column has also been identified as a risk factor for fish survival. In the context of global climate change, where PSTs are likely to become increasingly important, new insights and a synthesis of up‐to‐date information on fish response to PSTs and the risk associated with toxic dinoflagellate blooms are presented.