Coastal aquifers are essential freshwater sources for domestic, agricultural, and industrial use, particularly in regions where surface water is limited. However, these systems face growing stress from saltwater intrusion, climate-driven reductions in recharge, sea level rise, and intensified groundwater extraction. This review synthesizes recent research on coastal aquifer responses to these pressures, highlighting the interplay between natural hydrogeologic conditions and human-induced demand. Across deltaic and sedimentary systems, studies consistently show declining groundwater levels, the landward migration of saline interfaces, and reduced aquifer buffering capacity, especially in areas with high evaporation and limited recharge. The review also evaluates emerging strategies to preserve coastal groundwater security. Integrated hydrological models, managed aquifer recharge (MAR), optimized abstraction schemes, and remote sensing-based monitoring are advancing adaptive management capabilities. In parallel, policy and nature-based interventions—such as aquifer protection zoning, wetland rehabilitation, and dune system restoration—support long-term resilience by enhancing natural recharge and reducing vulnerability. The overall findings reveal the need for climate-informed and locally tailored groundwater management. Future efforts should prioritize coupling high-resolution climate projections with aquifer system models, evaluating MAR viability in saline-prone environments, and strengthening collaborative governance frameworks to ensure sustainable and equitable use of coastal aquifers.