The vine mealybug (VMB), Planococcus ficus, is a major grapevine pest worldwide, whose chemical control is often unsatisfactory due to its cryptic behavior, insecticide resistance and high fecundity rate. Recently, increasing restrictions have been applied to insecticides used for managing VMB. This review discusses sustainable VMB management strategies in organic viticulture. Pheromone-mediated mating disruption has been proved to be effective in both organic wine and table-grape vineyards. Biocontrol projects carried out through the release of parasitoids and/or predators have often provided inconclusive results, ranging from effective reduction of mealybug infestation to a marginal impact of parasitoids on VMB density. The latter outcome is likely due to constraints affecting the parasitoid activity, such as the disrupting activity of mealybug-tending ants and broad-spectrum insecticides, or untimely release of parasitoids. Ant suppression should be associated with the release of beneficial organisms, as mealybug-tending ants can severely affect the parasitoid activity. Cultural and physical control and the employment of entomopathogens and natural products mitigate the buildup of VMB populations, but they are not widely applied. VMB control in organic viticulture requires the integration of different strategies, as application of single control tools as a stand-alone treatment may not be effective, especially for high pest infestation. Future research to determine the density action threshold below which sustainable methods are effective and calibrate efforts in relation with pest infestation is needed. A multi-disciplinary approach is required to define the most appropriate sustainable control protocols in different environmental conditions and promote a further spread of organic viticulture.