The symptom of vascular neck pain, known as carotidynia, refers to throbbing pain of the neck and face with tenderness of the carotid artery. Recent publications suggest that carotidynia is a benign complaint, frequently associated with migraine, and often responding to migraine therapy. Past experience, and our own, indicates that carotidynia may be a symptom of other more serious disorders whose identification is essential to prevent subsequent catastrophic complications. 7 patients discussed in this publication presented with carotidynia. 4 have been reported previously. The associated disorders were dissecting aneurysm of the internal carotid artery (2 patients), long intraluminal clots with incomplete vessel obstruction of the internal carotid artery (2 patients), spontaneous aneurysm of the common carotid bifurcation (2 patients) and giant cell arteritis. We conclude that carotidynia is a symptom to be regarded with suspicion. The majority of patients encountered will have 'benign' carotidynia and angiography or exploratory surgery should not be routine. A rational approach to evaluation, investigation and treatment is presented.