Serotonin receptors modulate a variety of physiological processes ranging from perception, cognition and emotion to vascular and smooth muscle contraction, platelet aggregation, gastrointestinal function and reproduction. Drugs that interact with serotonin receptors effectively treat diseases as diverse as migraine headaches, depression, and obesity. Here, we present four structures of a prototypical serotonin receptor—the human 5-HT2B receptor—in complex with chemically and pharmacologically diverse drugs, including methysergide, methylergonovine, lisuride, and LY266097. A detailed analysis of these structures complemented by comprehensive interrogation of signaling illuminates key structural determinants essential for activation. Additional structure-guided mutagenesis experiments revealed binding pocket residues essential for agonist-mediated biased signaling and β-arrestin2 translocation. Given the importance of serotonin receptors for a large number of therapeutic indications, insights derived from these studies should accelerate the design of safer and more effective medications.