Otalgia, pain in the ear, can be a consequence of otologic disease (primary or otogenic otalgia), or can arise from pathologic processes and structures other than the ear (secondary or referred otalgia). In children, ear disease is far and away the most common cause of otalgia, but in adults, secondary or referred otalgia is more common. Otalgia can be the only presenting symptom of several serious conditions, and its etiology should be fully explored. Unfortunately, its workup is complex and no simple algorithm exists. This article outlines the common causes, presentation, and treatment options for primary and secondary otalgia.