Vasovagal syncope is a common condition, usually associated with a benign prognosis. Most sufferers experience only occasional symptoms, and can be treated with reassurance and lifestyle advice. However, a minority of patients are debilitated by frequent fainting that can infringe on daily living, or even mimic sudden death. This has been termed "malignant" vasovagal syncope because of the associated falls and physical injury. In these cases, a more interventional approach may be appropriate. Pharmacological measures have been the mainstay of treatment for recurrent vasovagal syncope: beta-blockers (e.g. atenolol), serotonin reuptake inhibitors (e.g. paroxetine), certain vasoconstricting drugs (e.g. midodrine) and fluid retaining agents (e.g. fludrocortisone) have been of particular interest. However, there is only mixed support from randomised controlled trials for the efficacy of these agents in preventing vasovagal syncope. 1,2,3 In the last few years, cardiac pacing has been advocated for the treatment of some forms of vasovagal syncope. This article reviews the literature and discusses the indications for pacing in vasovagal syncope.