A 30-year-old man had a long history of seizures that began with feelings of tightness in his throat and fear, followed by projectile vomiting and head and eye deviation to the left. These episodes were not completely controlled by antiepileptic medications. Video EEG monitoring confirmed his clinical description. Corticography was performed before and after temporal lobectomy and revealed residual spikes in the unresectable tissue of the insula. Three years postoperatively he has had no seizures with vomiting but has occasional 'auras' of throat tightening and fear. The case suggests that the insula may be a trigger area for emesis but requires anterior-mesial temporal cortex for completion.