With 368 people injured and an unknown number trapped under rubble, the figure of dead and wounded was expected to rise in the wake of the pre-dawn quake, Prime Minister Matteo Renzi warned.
"This is not a final toll," he said.
Hundreds of people were to spend a chilly night in hastily-assembled tents with the risk of aftershocks making it far too risky for them to return home.
Scores of buildings were reduced to dusty piles of masonry in communities close to the epicentre of the quake, which had a magnitude of between 6.0 and 6.2.
The devastated area is just north of L'Aquila, the city where some 300 people died in another quake in 2009.
More than half of the deaths occurred in and around the villages of Amatrice, Accumoli and Arquata del Tronto.
Guido Bordo, 69, lost his sister and her husband after they were trapped inside their holiday house in the hamlet of Illica, near Accumoli.
"There's no sound from them, we only heard their cats," he told AFP before the deaths were confirmed.
Sergio Camosi escaped in his underwear with his wife and daughter just before his house caved in.
"We ran down the stairs but the door was blocked by stones so we had to climb out the window," he said tearfully.
Among the victims was a nine-month-old baby girl whose parents survived, an 18-month-old toddler and two other young children who died with their parents in Accumoli.
Two boys aged four and seven were saved by their quick-thinking grandmother, who ushered them under a bed as soon as the shaking began, according to reports. She also survived but lost her husband.
It was Italy's most powerful earthquake since the 2009 disaster in L'Aquila.
"Half the village has disappeared," said Amatrice mayor Sergio Pirozzi, surveying a town centre that looked as if had been subjected to a bombing raid.
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