Here is the report for the {name} based on the details provided SUMMARY Bipolar disorder; migraines and epilepsy are three prevalent conditions, of which little is understood about their pathophysiological processes. Co-morbidities often present between two of these conditions, but it is uncommon for all three to coexist in a patient. Here, we present a middle-aged gentleman, seen in the outpatient department of a district general hospital in England, who suffers from severe effects of all three disorders, with no other medical history. Clinical difficulties have arisen in the diagnosis and treatment of his bipolar disorder. Management of his depressive episodes with simple selective serotonin reuptake inhibitors and mood stabilisers were either ineffective, or precipitated complicating adverse effects. Persistent use of citalopram is likely to have triggered bipolar disorder, whilst quetiapine induced seizures. The clinical problems presented question the possibility that bipolar disorder; migraines and epilepsy may fall on the same spectrum of disorders. This could contribute towards the complexities in treating his conditions. Further insight into their link and interactions would facilitate diagnoses of these conditions, as well as improve treatment strategies when they are presented co-morbidly. Key words: bipolar disorder – migraines – epilepsy - case report * * * * * INTRODUCTION Bipolar disorder; epilepsy and migraines are three common and broad-spectrum disorders, for which their pathophysiological mechanisms still remain uncertain. Epidemiological studies have shown that these conditions often exist as co-morbidities (Ortiz 2010, Ettinger 2005). Similarities in many respects have been descrybed in the literature, suggesting that a common pathophysiological process could explain their comorbid phenomenon. These include disease chronology and symptomatology; response to antiepileptic medication; and genes that are involved (Holland 2012). Comorbidities between two of these conditions are common, mainly involving migraines, but it is unusual for a patient to have all three conditions. Here, we present the case of a middle-aged gentleman, seen in the outpatient department of a district general hospital in England, who is severely affected by all of these disorders, with no other medical history. This case illustrates that bipolar disorder; migraines and epilepsy may fall on the same pathophysiological spectrum, which would have important implications in the individual management of these conditions. CASE REPORT The patient is a 41-year-old self-employed gentleman, presenting with eight year history of depression and mood instability, and one year history of migraines and seizures. The depression was exacerbated two years ago, after having been made redundant and had his house repossessed. Symptoms described included persistent low mood, and feeling like he wants to “curl up and die”. He had lost motivation in completing his college course, and partaking in other activities of interest. He was also noticed to become increasingly socially withdrawn. Somatic symptoms include sleep-onset insomnia; nocturnal wakenings, loss of appetite and weight. Further consultations over the course of one year elicited periods of elevated mood. These included overspending money; inappropriate social behaviours, such as phoning friends at early hours of the morning and getting himself into embarrassing situations. This included dancing around in public. He also described staying awake for up to 72 hours due to constant thoughts running through his mind, and works very effectively on his website during this time. These elevated moods can last up to 10 days in duration. In between the high and low moods, he describes feelings of intense anger, when he can attempt to be physically violent towards his mother. These symptoms fitted with a diagnosis of Bipolar II Disorder. His first seizure occurred five days after starting quetiapine, prescribed for his bipolar disorder. He described waking up with a sore mouth, having been doubly incontinent, and felt very drowsy the following day. Despite withdrawal of quetiapine after this episode, he still suffers from approximately four similar nocturnal generalised seizures per month. The diagnosis of epilepsy was made following consultation with a neurologist. Migraines were first documented one year ago. They have been described to be severe, unilateral headaches that are associated with monocular visual loss. They limit activities of daily living, and the patient has reported missing various appointments due to these. The migraines tend to occur during the transition between his high and low moods