Pugh was listed on Forbes' annual 30 Under 30 list, which recognises the 30 most influential people in Europe under the age of 30, in 2019. She was also recognised as having a breakthrough in the same year, during which she starred in three major films. She first starred as professional wrestler Paige in Fighting with My Family, a comedy-drama about Paige's relationship with her family, co-starring Lena Headey and Dwayne Johnson. The film premiered at the 2019 Sundance Film Festival to critical acclaim. Geoffrey Macnab of The Independent noted how different the role was from Pugh's previous appearances, and wrote that she was "completely convincing as the wrestler" and that she showed "the same defiance, scruffy glamour and self-deprecating humour as the real life [. . . ] Paige. " She next played the lead role in Ari Aster's horror film Midsommar, which chronicles a troubled couple who encounter Swedish cultists. David Edelstein of Vulture called her performance "amazingly vivid" and wrote, "Her face is so wide and open that she seems to have nowhere to hide her emotions. "