Carotid sinus massage was carried out on 130 consecutive patients referred for investigation of dizziness, syncope or unexplained falls. Carotid sinus syndrome was diagnosed in 33 for whom no other cause of symptoms was identified. Right-sided hypersensitivity was more frequent than left-sided. Thirty per cent identified a prodrome before syncope and 30% had retrograde amnesia for the event. In 52%, symptoms were precipitated by head movement and in 48% by vagal stimuli. Seven described 'drop attacks' but symptoms were reproduced with carotid sinus massage during head-up tilt. Injuries, including fractured neck of femur, were sustained by the majority. Carotid sinus massage should be performed routinely on all elderly patients who have symptoms of unexplained dizziness, falls or syncope. Cardiac pacing relieves syncopal symptoms in those with a predominant cardio-inhibitory response and recurrent syncope.