Tetrahydroisoquinoline alkaloids (THIAs) are a prominent class of plant-derived compounds with various important pharmaceutical applications. Considerable progress has been made in the biosynthesis of THIAs in microorganisms due to the elucidation of their natural biosynthetic pathways and the discovery of key enzymes. In this review, we systematically summarize recent progress in elucidating the natural biosynthetic pathways of THIAs and their biosynthesis in industrial microorganisms. In addition, recent advancements in the synthesis of THIAs through the construction of artificial multi-enzyme cascades and chemoenzymatic cascades are highlighted. Finally, the current challenges in developing efficient cell factories for producing THIAs are discussed, along with proposed strategies aimed at providing insights into the industrial production of THIAs.