Despite converging treatment guidelines, current treatment practices in bipolar mania still vary greatly. We will review the evidence for various pharmacological options for bipolar mania – in the acute inpatient setting, in continuation therapy, and long-term in the outpatient maintenance setting as well as key treatment guidelines. Potential explanations for the existence of gaps between real life clinical practices and treatment guidelines will be presented. Although there is reasonable satisfaction with current treatments for bipolar mania among European psychiatrists, treatment resistance and early relapses are quite frequent. Thus, there is a need for improved treatments in both the acute and maintenance settings. Patients with an acute episode of bipolar mania often enter the healthcare system at the emergency room and are subsequently moved to a psychiatric hospital ward. Following resolution of an acute episode, prevention of relapse (manic or depressive) becomes the principal aim of treatment. Thus, the focus is moving toward evaluating differently the risk/benefit ratio in the acute inpatient setting and in the long term maintenance setting. The focus also moves towards achieving better patient functioning and long-term outcomes so that patients can achieve functional remission. Different treatment options for each stage of the illness will be reviewed. A core medical need in bipolar mania treatment paradigms in Europe is a rapid-acting efficacious agent, with low potential for excessive sedation. The potential for emerging options to fulfil this need will be reviewed.