Head up tilt testing (HTT) is now commonly used to investigate otherwise unexplained syncope and presyncope.  This test has been used for over 20 years primarily to diagnose neurally mediated syncope, but HTT’s exact role in the diagnostic process remains uncertain.  Recognized limitations include poor reproducibility, lack of prognostic role, and insufficient randomized studies to guide therapeutic choice.  In this review, we describe the indications and methods recommended by present guidelines on utilizing HTT.  In addition, present criticisms and limitations of this test, along with future perspectives, are outlined.