The use of plant-based feed additives (PBFAs) in Nile tilapia aquaculture is gaining attention as a sustainable alternative to synthetic inputs, with reported benefits for growth, immunity, and disease resistance. This review synthesizes evidence on PBFAs, including crude powders, extracts, essential oils, and purified bioactives, from plants such as garlic, ginger, aloe vera, and moringa. Their effects involve interconnected pathways, including immunomodulation, antioxidant defense, antimicrobial activity, host–microbiome modulation, molecular signaling, and reproductive or endocrine regulation, thereby supporting growth performance, feed efficiency, physiological resilience, reproductive indices, and survival after pathogen challenge. However, commercial adoption is constrained by phytochemical variability, limited standardization, incomplete understanding of species- and context-dependent responses, and regulatory gaps. Future work should prioritize mechanistic validation, optimized formulation, and practical delivery strategies for sustainable Nile tilapia production.