Carotid sinus hypersensitivity was first reported more than 200 years ago. Nevertheless, a complete understanding of this relatively common clinical finding in older patients has proven elusive. There is evidence to support an association between symptoms, particularly syncope, and a hypersensitive response to carotid sinus massage. However, the clinical implication of a high prevalence in asymptomatic healthy older persons is not known. A central degenerative process likely underlies the pathophysiology, but this is as yet unproven. Although selected patients have had symptom improvement with treatment, particularly permanent pacing, there is a dearth of randomized controlled trial data to guide management.