West Virginians, living where rugged terrain prevented good rooftop-antenna reception in many places, were pioneers in the development of cable television. An entrepreneur, often a local television dealer, erected an antenna on a hilltop with good reception, amplified the incoming signal, and then brought it by wire down the hill into the homes below. Countless single-home systems were installed as well, as were many co-ops serving a few houses. The state's first commercial cable installations, at Piedmont, Mineral County, and Cameron, Marshall County, began operating in late 1949 and early 1950. The early unshielded wire systems, fragile in construction and subject to interference, were succeeded by shielded coaxial cable, already in use by hotels and apartment houses in larger American cities. The first coaxial cable systems in West Virginia began operating at Welch on July 1, 1951, and shortly after at Richwood, both receiving WSAZ-TV, Huntington.

Equipment was primitive in the early 1950s, and the first cable systems could carry no more than three channels, if that many were receivable at the antenna site, often not the case. Improved amplifiers made it possible to offer as many as five channels by the end of 1954, when there were rapidly growing cable systems in more than two dozen communities ranging in size from Webster Springs to Wheeling. Due to its rugged terrain, West Virginia had the highest number of cable subscribers per capita in the country. The state's early importance in cable television made its operators especially influential in steering the business nationally. For many years, more West Virginians served as officers and directors of the industry's trade association than was the case for any other state.

As early as 1955, the legislature considered declaring TV cable companies to be public utilities subject to regulation by the Public Service Commission. However, system owners succeeded in staving off governmental oversight several times, and it was not until 1988 that cable TV was brought under limited regulation. Meanwhile, the Federal Communications Commission had reserved to itself the authority to regulate rates for cable service.

Beginning nationally in the 1970s, major broadcasting companies, movie studios, other entertainment and media entities, and phone companies began acquiring cable systems and creating nationwide operations. In time, most West Virginia owners sold out to the conglomerates; by the year 2000, there were few independent operators still in business. The new owners rebuilt the old systems, employing fiberoptic cables and other newly developed equipment that vastly increased the numbers of channels available. They also broadened their businesses, offering customers Internet access and telephone service.

With online streaming services now readily available in areas with adequate Internet connectivity, many viewers have switched away from cable completely. As of 2010, there were 23 cable companies operating in West Virginia. The biggest providers were Suddenlink, Comcast, Time Warner, Shentel, and Armstrong. At that time, close to 90 percent of West Virginia's household had access to cable, and about 67 percent of those households subscribed to the service. In 2021, a poll suggested that just more than half of West Virginia television owners now subscribe to cable; however, the poll showed that access to both cable and streaming services was significantly affected by household income. Leading cable companies now include Optimum (formerly Suddenlink), Comcast, Xfinity, Centre TV, Spectrum, and Shentel, all of which offer Internet services, as well.