A portfolio of water management strategies now exists to contribute to reach water demand and supply targets. Among them, integrated water resource management has a large potential for reducing water disagreement in water scarcity regions. Many of the strategies are based on well tested choices and technical know-how, with proven benefits for users and environment. This paper considers water management practices that may contribute to reduce disagreement in water scarcity areas, evaluating the management alternatives in the Mediterranean basins of Europe, a region that exemplifies other water scarcity regions in the world. First, we use a model to compute water availability taking into account water management, temporal heterogeneity, spatial heterogeneity and policy options, and then apply this model across 396 river basins. Second, we use a wedge approach to illustrate policy choices for selected river basins: Thrace (Greece), Guadalquivir, Ebro, Tagus and Duero (Spain), Po (Italy) and Rhone (France). At the wide geographical level, the results show the multi-determinant complexities of climate change impacts and adaptation measures and the geographic nature of water resources and vulnerability metrics. At the local level, the results show that optimisation of water management is the dominating strategy for defining adaptation pathways. Results also show great sensitivity to ecological flow provision, suggesting that better attention should be paid to defining methods to estimate minimum ecological flows in water scarcity regions. For all scales, average water resource vulnerability computed by traditional vulnerability indicators may not be the most appropriate measure to inform climate change adaptation policy. This has large implications to applied water resource studies aiming to derive policy choices, and it is especially interesting in basins facing water scarcity. Our research aims to contribute to shape realistic water management options at the regional level and therefore provide information to climate change, agricultural and water policies.