Extreme floods, with multi-century to millennia recurrence intervals, arise from a combination of antecedent watershed characteristics and unusual or rare atmospheric circulations that occur too infrequently to discern drivers from instrumental records. Few stream gauge records in the United States contain 100 years or more of annual peak flow data, meaning rare extreme floods are underrepresented in the peak flow population. We synthesized approximately 8,000 years of paleoflood hydrologic data from multiple studies and various landforms (floodplains, rock shelters, and caves) conducted in the Tennessee River Valley between Chattanooga, Tennessee, and Florence, Alabama, to examine Holocene flood variability. Extreme floods (>11,000 m3/s) clustered around ∼7,900, 6,000–4,900, and ∼1,000–80 cal yrs BP. More moderate floods occurred between 4,800 and 2,000 cal yrs BP. We compared flood variability in the Tennessee Valley to Holocene paleorecords available in North America. All periods of extreme flooding occurred during large-scale, abrupt climate transitions that lacked a distinct directionality of temperature change (i.e., warm to cool or cool to warm). Our findings indicate that extreme floods clustered in times when (1) warm-season precipitation increased, (2) abrupt increases in precipitation followed episodes of drought, and (3) the rate of change in the hydroclimate regimes was greater than the rate of morphological change in response to increased moisture, thus, exceeded geomorphic thresholds. Internal river basin factors such as drought-induced watershed changes and river morphological changes are key flood drivers that set the stage for flood response to changes in precipitation. Our findings suggest that anticipated changes to drought and precipitation intensity due to modern climate change may increase extreme floods, particularly for urban and regulated rivers not given the space for adjusting to higher precipitation variability.