Syncope occurring in the setting of head and neck malignancy may have several possible causes. Local effects of a tumour in the parapharyngeal area may produce a syncopal syndrome similar to carotid sinus hypersensitivity, but with distinctive differentiating features. This article presents a case of profound vasodepressor syncope in a patient with recurrent pharyngeal malignancy, and discusses the mechanisms by which this occurs and the possible therapeutic options.