An implantable medical lead is provided with a distal guidewire extension. A flexible distal guidewire extension, which may take the form of a helically wound wire around a tapered core, extends from the distal end of a lead body. The extension may exit a tip electrode, which may be a generally rounded electrode or an active fixation electrode. The distal guidewire extension is preferably insulated, but may be provided with an uninsulated segment for serving as an electrode.