Fusarium mycotoxins in cereals constitute major problems for animal and human health worldwide. A range of plant pathogenic Fusarium species that can infect cereal plants in the field are considered the most important source of mycotoxins, such as deoxynivalenol (DON), zearalenone (ZEA), T-2 toxin, and HT-2 toxin, in small-grain cereal crops in temperate climates. In this article, we (i) critically review the available knowledge on the impact of contrasting production systems (organic versus conventional) and specific agronomic parameters on the occurrence and concentrations of DON, ZEA, and T-2/HT-2 in small-grain cereals (wheat, oats, barley, and rye), and (ii) discuss Fusarium mycotoxin risks in the context of the need to develop more sustainable cereal production systems. Overall, the available evidence from studies of acceptable scientific quality suggests that the incidence and concentrations of Fusarium mycotoxin are lower in organic compared with conventional cereals. Specifically, 24 comparisons showed lower mycotoxin levels in organic production, 16 detected no significant difference, and only 2 showed higher levels in organic production. When the mean concentrations from all studies were compared, conventionally produced cereals had 62%, 110%, and 180% higher concentrations of DON, ZEA, and T-2/HT-2, respectively, than organic cereals. Overall, published studies on the effects of specific agronomic practices on mycotoxin levels suggest that diverse crop rotations and high soil organic matter content/biological activity are associated with a lower risk of Fusarium mycotoxin contamination, whereas (i) high mineral nitrogen fertiliser inputs, (ii) some fungicides and herbicides, and (iii) minimum or no tillage may increase the risks of Fusarium mycotoxin contamination in cereals. The management of Fusarium head blight and mycotoxins, therefore, requires a preventative, integrated, holistic agronomic approach.