Enhancing nitrogen removal is a very active branch in municipal wastewater treatment research, toward this end, anammox technology is a sustainable solution. This review systematically outlines the strategies employed to enhance mainstream anammox performance, including nitrite accumulation and microbial enrichment based on partial nitrification coupled anammox and partial denitrification coupled anammox, developed to address the challenges of low ammonium content in wastewater, nitrate accumulation in the effluent, and the influence of organic matter. The characteristics and advantages of novel anammox-coupled processes, including partial nitrification and partial denitrification coupled anammox, endogenous partial denitrification coupled anammox, and denitrifying anaerobic methane oxic coupled anammox are also comprehensively discussed; these aim to ensure the highly efficient and stable operation of anammox under diverse wastewater conditions by constructing a composite biological nitrogen removal system based on anammox, supplemented by nitrification-denitrification and other processes. Additionally, a novel anammox application route including mainstream partial denitrification/anammox and absorptionbiodegradation as well as sidestream partial nitrification/anammox is proposed, and its application pathway in conceptual wastewater treatment plants is outlined, aiming to foster the development of cost-effective, efficient, and energy-saving advanced wastewater treatment processes. Finally, prospects are presented that indicate the gaps in contemporary research and potential future research directions. Overall, this review provides a reference for treating municipal wastewater with anammox and sheds new light on related strategies and nitrogen removal mechanisms.