Photoacoustic microscopy (PAM) is a key implementation of photoacoustic imaging (PAI). PAM merges rich optical contrast with deep acoustic detection, allowing for broad biomedical research and diverse clinical applications. Recent advancements in PAM technology have dramatically improved its imaging speed, enabling real-time observation of dynamic biological processes in vivo and motion-sensitive targets in situ, such as brain activities and placental development. This review introduces the engineering principles of high-speed PAM, focusing on various excitation and detection methods, each presenting unique benefits and challenges. Driven by these technological innovations, high-speed PAM has expanded its applications across fundamental, preclinical, and clinical fields. We highlight these notable applications, discuss ongoing technical challenges, and outline future directions for the development of high-speed PAM.