The natural disaster piled on many human-made ones, multiplying the suffering in Aleppo and Syria more broadly.
Fighting largely halted in Aleppo in 2016, but only a small number of the numerous damaged and destroyed buildings had been rebuilt. The population has also more recently struggled with Syria's economic downslide, which has sent food prices soaring and residents thrown into poverty.
The shock of the quake is all too much.
Hovig Shehrian said that during the worst of the war in Aleppo, in 2014, he and his parents fled their home in a front-line area because of the shelling and sniper fire. For years, they moved from neighborhood to neighborhood to avoid the fighting.
``It was part of our daily routine. Whenever we heard a sound, we left, we knew who to call and what to do,'' the 24-year-old said.
``But . we didn't know what to do with the earthquake. I was worried we were going to die.''
Monday's pre-dawn 7.8-magnitude quake, centered about 70 miles (112 kilometers) away in Turkey, jolted Aleppans awake and sent them fleeing into the street under a cold winter rain. Dozens of buildings across the city collapsed. More than 360 people were killed in the city and hundreds of others were injured. Workers were still digging three days later through the rubble, looking for the dead and the survivors. Across southern Turkey and northern Syria, more than 11,000 were killed.
Even those whose buildings still stood remain afraid to return. Many are sheltering in schools. A Maronite Christian monastery took in more than 800 people, particularly women, children and the elderly, crammed into every room.
``Until now we are not sleeping in our homes. Some people are sleeping in their cars,'' said Imad al-Khal, the secretary-general of Christian denominations in Aleppo, who was helping organize shelters.
For many, the earthquake was a new sort of terror _ a shock even after what they endured during the war.
For Aleppo, the war was a long and brutal siege. Rebels captured the eastern part of the city in 2012, soon after Syria's civil war began. For the next years, Russian-backed government forces battled to uproot them.
Syrian and Russian airstrikes and shelling flattened entire blocks. Bodies were found in the river dividing the two parts of the city. On the government-held western side, residents faced regular mortar and rocket fire from opposition fighters.
A final offensive led to months of urban fighting, finally ending in December 2016 with government victory. Opposition fighters and supporters were evacuated, and government control imposed over the entire city. Activist groups estimate some 31,000 people were killed in the four years of fighting, and almost the entire population of the eastern sector was displaced.
Aleppo became a symbol of how President Bashar Assad succeeded in clawing back most opposition-held territory around Syria's heartland with backing from Russia and Iran at the cost of horrific destruction. The opposition holds a last, small enclave in the northwest, centered on Idlib province and parts of Aleppo province, which was also devastated by Monday's quake.
But Aleppo never recovered. Any reconstruction has been by individuals. The city's current population remains well below its pre-2011 population of 4.5 million. Much of the eastern sector remains in ruins and empty.
Buildings damaged during the war or built shoddily during the fighting regularly collapse. One collapse, on Jan. 22, left 16 people dead. Another in September killed 11 people, including three children.
Aleppo was once the industrial powerhouse of Syria, said Armenak Tokmajyan, a non-resident fellow at Carnegie Middle East who is originally from the city. Now, he said, it's economically marginalized, basic infrastructure in gas and electricity is lacking, and its population - which had hoped for improvements after fighting ended - only saw things get worse.
They have also now experienced the physical, and psychological, blow of the earthquake, Tokmajyan said. ``It left them wondering, do they really deserve this fate or not? I think the trauma is big and it will take some time until they swallow this really bitter pill after (more than) 10 years of war.''
Rodin Allouch, an Aleppo native, covered the war for a Syrian TV station.
``I used to be on the front line, getting video shots, getting scoops. I was never scared. Rockets and shells were falling and everything, but my morale was high,'' he recalled.
The earthquake was different. ``I don't know what the earthquake did to us exactly. We felt we were going to join God. It was the first time in my life I got scared.''
During the war, he had to leave his neighborhood in the eastern sector and rent an apartment on the western side. But the quake has displaced him yet again. As their building shook, he, his wife and four children fled to a nearby garden. Allouch said he won't return until the building is inspected and repaired. It still stands, but has many cracks. The family will instead stay in a ground-floor store front nearby that he rented.
``It is safer to be down (on ground floor) if there is an earthquake,'' he said, but complained that there is no fuel for heating. ``Life is so miserable.``
Many others in Aleppo have been displaced more than once.
Farouk al-Abdullah fled his farm south of Aleppo city during the war. Since then, he has been living with his two wives, 11 children and 70-year-old mother in Jenderis, an opposition-held town in Aleppo province.
Their building there collapsed completely in the earthquake, though the entire family was able to escape.
He said the earthquake, with its destruction everywhere and its aftermath _ watching rescue crews pull bodies out of the rubble _ ``are much more horrible than during the war.``
And while war may be senseless, those in it often have a cause they are sacrificing for and wrest some meaning out of the death and destruction.
The war's devastation in Aleppo at least ``is somehow a proof that we weren't defeated easily,'' said Wissam Zarqa, an opposition supporter from the city who was there throughout the siege and now lives in the Turkish capital Ankara.
``But the destruction of natural disasters is all pain and nothing else but pain.''