Thousands of people in central Italy are spending the night in cars, tents and temporary accommodation following the fourth earthquake in the area in three months.
The 6.6-magnitude quake - Italy's strongest in decades - struck close to the region where nearly 300 people were killed by a quake in August.
This time no-one appears to have died, but about 20 people were injured.
Powerful aftershocks are still bringing down masonry.
In the town of Norcia, in Perugia region, close to the epicentre of Sunday morning's earthquake, some locals have decided to stay in their homes.
Others will spend the night in tents pitched near the town or are taking up the authorities' offer of shelter on the Adriatic Coast.
"It will be a difficult night," the head of Italian Civil Defence, Fabrizio Curcio. "A 6.5 earthquake has clearly changed the situation."
Norcia resident Stefano Boldrini, who is now living in a van with his eight-year-old daughter, was asked if they planned to stay in the area.
"No, how could we? There's no more school, or church, or police station. There's nothing here any more," he said.
The medieval basilica of St Benedict in Norcia was among many historic buildings and structures that were destroyed.
An evacuation of buildings in central Italy deemed vulnerable to seismic activity last week, following strong aftershocks from August's quake, may have saved lives.
Officials said three people were dug out of the rubble alive in the town of Tolentino.
Giuseppe Pezzanesi, mayor of Tolentino, said the small town had "suffered our blackest day yet.
"The damage is irreparable. There are thousands of people in the streets, terrified, crying. Let's hope that is an end to it, the people are on their knees psychologically." Read More
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