Vasovagal syncope is a common clinical problem forming the pathophysiological basis of half the cases of syncope. Although it usually has a favourable prognosis, it may be a highly limiting clinical problem in a particular subset of patients among whom syncopal recurrences are frequent and without prodromic symptoms, or have a traumatic outcome. For this subgroup of patients the term "malignant vasovagal syncope" has been proposed. The treatment of these highly symptomatic patients is necessary to avoid dangerous injuries and to improve the quality of life. Pacemaker therapy has been advocated as a potential therapy in severe or drug refractory cases. This paper reviews the concepts behind pacemaker therapy for vasovagal syncope and the results of various clinical trials that have evaluated its potential utility as a primary therapeutic modality.