Purpose Main purposes of pre-acclimatization by hypoxia conditioning (HC) are the prevention of high-altitude illnesses and maintenance of aerobic exercise performance. However, robust evidence for those effects or evidence-based guidelines for exposure strategies, including recommendations to ensure safety, are largely lacking. Therefore, we summarize the current knowledge on the physiology of acclimatization to hypoxia and HC with the aim to derive implications for pre-acclimatization strategies before going on high-altitude treks and expeditions. Methods Based on the literature search and personal experience, core studies and important observations have been selected in order to present a balanced view on the current knowledge of high-altitude illnesses and the acclimatization process, specifically focusing on pre-acclimatization strategies by HC. Results and Conclusions It may be concluded that in certain cases even short periods (e.g., 7 h) of pre-acclimatization by HC are effective, but longer periods (e.g., > 60 h) are needed to elicit more robust effects. About 300 h of HC (intermittently applied) may be the optimal preparation for extreme altitude sojourns, although every additional hour spent in hypoxia may confer further benefits. The inclusion of hypobaric exposures (i.e., real altitude) in pre-acclimatization protocols could further increase their efficacy. The level of simulated altitude is progressively increased or individually adjusted ideally. HC should not be terminated earlier than 1–2 weeks before altitude sojourn. Medical monitoring of the pre-acclimatization program is strongly recommended.