High-performance cast magnesium rare-earth (Mg-RE) alloys are one of the most important materials among all developed Mg alloy families, and have shown great potential in military and weapons, aerospace and aviation, orthopedic implants, etc. Controlling grain size and distribution of it is key to the promising mechanical performance of Mg-RE alloy casting components. During the casting of a real component, nearly every procedure in the fabrication process will influence the grain refinement effect. The procedure may include and may not be limited to the chemical inoculations, possibly applied physical fields, the interfere between grain refiner and purifications, and the casting techniques with different processing parameters. This paper reviews the recent advances and proposed future developments in these categories on grain refinement of cast Mg-RE alloys. The review will provide insights for the future design of grain refinement techniques, the choosing of processing parameters, and coping strategies for the failure of coarsening for cast Mg-RE components with high quality and good performance.