IMPORTANCE: The relief of pain after tonsillectomy in children remains challenging and even controversial. While the need for pain control after this surgery is understood, recent debate has centered around the risks of opioids in children with obstructive sleep apnea syndrome (OSAS) and the possible increases in posttonsillectomy hemorrhage with the use of alternative nonsteroidal anti-inflammatory drugs (NSAIDs). OBSERVATIONS: We discuss the multiple facets of posttonsillectomy pain control in children. A variety of pharmacologic and nonpharmacologic interventions used before, during, and after surgery are reviewed, presenting the evidence for efficacy and possible adverse effects. We also review the various surgical techniques used in tonsillectomy with a focus on reducing postoperative pain. CONCLUSIONS AND RELEVANCE: Clinicians should understand effective methods of analgesia after tonsillectomy in children, and know the potential consequences of each option. Caution should be employed when using opioids, particularly in young children with severe OSAS. Although large studies of NSAID use have shown effective pain management without an increase in posttonsillectomy bleeding frequency, the potential for more severe bleeding events has been debated. Cold dissection techniques lead to less pain, but hot techniques remain popular, with less intraoperative blood loss and shorter operative time. Partial (intracapsular) tonsillectomy seems to reduce pain as well.