Floods and droughts are important features of most running water ecosystems, but the alteration of natural flow regimes by recent human activities, such as dam building, raises questions related to both evolution and conservation. Among organisms inhabiting running waters, what adaptations exist for surviving floods and droughts? How will the alteration of the frequency, timing and duration of flow extremes affect flood- and drought-adapted organisms? How rapidly can populations evolve in response to altered flow regimes? Here, we identify three modes of adaptation (life history, behavioral and morphological) that plants and animals use to survive floods and/or droughts. The mode of adaptation that an organism has determines its vulnerability to different kinds of flow regime alteration. The rate of evolution in response to flow regime alteration remains an open question. Because humans have now altered the flow regimes of most rivers and many streams, understanding the link between fitness and flow regime is crucial for the effective management and restoration of running water ecosystems.